Moonlighting in a private office

[HolisticMed]

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I have some pretty specific questions regarding moonlighting and I'm not quite sure where to find the answer. I am a PM&R resident and would like to moonlight at a family friends chiropractic office doing manipulation, interpreting emg's, exercise rehab etc... I was offered an excellent financial incentive to work here however they will not pay for my malpractice insurance. Does anybody know how much malpractice insurance costs for a pgy-2 resident working in a private practice? Also, I assume that I have the right to accept/bill insurance as a provider even though I am a resident. Am I correct in this assumption? Also, when you do bill insurance for the care that you provided, is the insurance reinbursing you as a physiatrist or as a general practitioner. Any help is greatly appreciated. Thanks

👍👍

 

[gutonc]

This setup, while initially enticing, is likely to bring you nothing but pain, now and in the future. The reason they don't want to pay your med-mal is that, as a non-BC/BE physician, it is likely to be astronomical (I'm going to say mid-5 figures a year but I'm pulling that # out of my butt). Also, as a non-BC/BE physician, CMS and likewise most private insurers who tend to follow most CMS rules, won't pay when you bill for your services. Since you're not actually a physiatrist, you can't bill as one (again w/ the non-BC/BE thing). Cash payments are about all that you can reasonably expect to get in this situation. I may be wrong about this (and someone will no doubt correct me if I am).

You need to also make sure that you're not running afoul of any rules/regs put in place by your training program or institution. Some places don't allow moonlighting at all, others only allow internal moonlighting and others have no restrictions...don't jeopardize your future for a few extra Benjamins now.

 

[Winged Scapula]

I have some pretty specific questions regarding moonlighting and I'm not quite sure where to find the answer. I am a PM&R resident and would like to moonlight at a family friends chiropractic office doing manipulation, interpreting emg's, exercise rehab etc... I was offered an excellent financial incentive to work here however they will not pay for my malpractice insurance. Does anybody know how much malpractice insurance costs for a pgy-2 resident working in a private practice?

Varies widely. Will depend on your state, city, and whether or not they determine that doing what you are proposing is practicing outside of your scope of practice (in which case you probably won't get insurance). An insurance agent can give you some quotes for coverage but I'll bet that since you are not working under the auspices of a residency training program, the cost will be prohibitive if you can get it at all. Another consideration is the tail. You'll have to pay for coverage for after you leave this position as well, in case someone sues you a few years down the line.

Does your program allow you to moonlight? You also should have an unrestricted license as well.

Also, I assume that I have the right to accept/bill insurance as a provider even though I am a resident. Am I correct in this assumption?

To bill an insurance company you have to have an NPI number (easy to get) AND be a contracted insurance provider. The latter is not so easy and may take months. You will find it hard to get on insurance plans without being BE/BC.

Also, when you do bill insurance for the care that you provided, is the insurance reinbursing you as a physiatrist or as a general practitioner. Any help is greatly appreciated. Thanks

👍👍

You are reimbursed as a physician. Payment is determined by the CPT code and not the type of physician you are.

 

[Blade28]

I am a PM&R resident and would like to moonlight at a family friends chiropractic office doing manipulation, interpreting emg's, exercise rehab etc... I was offered an excellent financial incentive to work here however they will not pay for my malpractice insurance.

Do you have your full state license already? Are you licensed to practice manipulation?

In general paying for your own malpractice insurance policy can be quite expensive - try getting a quote from any number of your state's preferred providers.

Edit: I thought you were an MS-III? 😕

 

[core0]

This setup, while initially enticing, is likely to bring you nothing but pain, now and in the future. The reason they don't want to pay your med-mal is that, as a non-BC/BE physician, it is likely to be astronomical (I'm going to say mid-5 figures a year but I'm pulling that # out of my butt). Also, as a non-BC/BE physician, CMS and likewise most private insurers who tend to follow most CMS rules, won't pay when you bill for your services. Since you're not actually a physiatrist, you can't bill as one (again w/ the non-BC/BE thing). Cash payments are about all that you can reasonably expect to get in this situation. I may be wrong about this (and someone will no doubt correct me if I am).

You need to also make sure that you're not running afoul of any rules/regs put in place by your training program or institution. Some places don't allow moonlighting at all, others only allow internal moonlighting and others have no restrictions...don't jeopardize your future for a few extra Benjamins now.

The other issue about malpractice is you need to pay a tail also. So if you get med mal for one year you essentially have to pay twice. I would guess low five figures depending on how they classify you.

David Carpenter, PA-C

 

[Tired]

So a medical degree qualifies you work as a chiropractor? That's pretty bizarre.

 

[HolisticMed]

Thanks for the all of the responses, you definitely brought up some issues that I was not previously aware of.

I went to an osteopathic school and therefore learned to utilize manipulation. I spent a good deal of extra time practicing both in the first couple of years and through elective OMM rotations.

As far as cpt codes go, here is my question. I know that for example a physiatrist who does exercise rehab with a patient can bill at a higher level code that an fp doc who trys to do this. Insurance reimbursement will pay some providers at higher rates for the same procedure that it will pay another doc who not as well trained in that area. So that is why I was asking if as a resident you are billing as a GP or as a doctor within that particular specialty.

This practice sees a tremendous volume of patients and so the potential to make enough money to pay my own malpractice insurance as well as to make a substantial amount more money is certainly there but the question becomes can I bill insurance? Will plans accept you as a provider if your still a resident? And do you they reimburse you as a GP.

Thanks for all of the help 👍

 

[Winged Scapula]

As far as cpt codes go, here is my question. I know that for example a physiatrist who does exercise rehab with a patient can bill at a higher level code that an fp doc who trys to do this. Insurance reimbursement will pay some providers at higher rates for the same procedure that it will pay another doc who not as well trained in that area. So that is why I was asking if as a resident you are billing as a GP or as a doctor within that particular specialty.

That doesn't make much sense to me unless the physiatrist has contracted a higher rate but admittedly I am not familiar with anything other than E&M codes and surgical procedures. However, it is true that Medicare does have some rules about who can order what tests, etc. (ie, only certain physicians can order scooters for patients)

Medicare sets its rates and while they may vary for part of the country/city, I am not aware that they pay any physician differently for doing the same procedure.

Most insurance companies reimburse as a percentage of Medicare rates; and that percentage will depend on what you negotiate. I may make more or less than the surgeon next door simply as a function of contracted rates so they do pay differently.

Perhaps what you have seen is that the physiatrist is able to get a higher rate than the FP because he/she has simply negotiated their contract to get a higher rate. I am unable to find information on whether or not they vary their reimbursement based on specialty but given that you are not a physiatrist yet, I would imagine that you would be reimbursed at the lesser rate if you could indeed get on plans.

FYI: Here is a link to an archived thread in which drusso talks about reimbursement for common physiatry E&M and procedure codes (note that its 2003 data): http://forums.studentdoctor.net/archive/index.php/t-62435.html Bear in mind that outside of Medicare, what you are supposed to be paid and what you are actually paid, may be entirely different.

 

[Winged Scapula]

This practice sees a tremendous volume of patients and so the potential to make enough money to pay my own malpractice insurance as well as to make a substantial amount more money is certainly there but the question becomes can I bill insurance? Will plans accept you as a provider if your still a resident? And do you they reimburse you as a GP.

Thanks for all of the help 👍

You'll have to contact some plans and see what their requirements are.

First you will need an unrestricted medical license.

Secondly, you will nee an NPI number.

Thirdly, you have to apply to individual plans and Medicare. Expect some plans to take up to a year to approve you as a contracted provider. I've been waiting for 7 months for United HealthCare. Medicare is usually the quickest - 45 days or so.

Some programs may allow you to be a provider and others will not. The practice you are considering joining should be able to provide you with the Physician Services Reps for each of the insurance plans they commonly see and you should speak to them about whether or not you would be eligible. I will imagine that most, if not all, plans will not consider you without being BE.

 

[roja]

The other issue about malpractice is you need to pay a tail also. So if you get med mal for one year you essentially have to pay twice. I would guess low five figures depending on how they classify you.

David Carpenter, PA-C

Absolutely key advice. Some places will advice you to not buy the tail. (its cheaper) but in the long run, absolutely do NOT buy malpractice without tail coverage.

 

[sunlioness]

Will plans accept you as a provider if your still a resident? And do you they reimburse you as a GP.

Thanks for all of the help 👍

Not around here they won't. "Around here" being PA. I can't speak to other states, but I imagine it's similar.

 

[HolisticMed]

"Not around here they won't. Around here being PA. I can't speak to other states, but I imagine it's similar."

Do you happen to know any residents that have been approved to be a provider for any private insurance companies or medicare?

If you have malpractice insurance but your not a provider for any particular insurance company, can you bill for out of network reimbursement?

Insurance will reimburse "specialist" physicians for procedures that they simply will not reimburse general physicians for. There are definitely several different modalities that physiatrists will get reimbursed for that an fp would not. I would assume that you would be considered similar to an fp doc regardless of your current residency program, therefore being prohibited from billing those codes which are specific to your specialty.

Also once you pass step three is receiving your license and your NPI number a formality? What does this process entail?

Thanks for much for all your help, this info is invaluable to me.

 

[sunlioness]

Do you happen to know any residents that have been approved to be a provider for any private insurance companies or medicare?

Nope, not a one. Even in my training program I can't see privately insured or medicare patients. These are all seen by attendings. I am only able to see medicaid patients. I do have one patient I see for psychotherapy who is medicare, but I can't bill for it unless I have been directly observed the entire time by a supervisor and then she's the one who bills.

If you have malpractice insurance but your not a provider for any particular insurance company, can you bill for out of network reimbursement?

No. It's not a matter of being in network. They don't think you're qualified to be seeing their patients period.

Insurance will reimburse "specialist" physicians for procedures that they simply will not reimburse general physicians for. There are definitely several different modalities that physiatrists will get reimbursed for that an fp would not. I would assume that you would be considered similar to an fp doc regardless of your current residency program, therefore being prohibited from billing those codes which are specific to your specialty.

FP is a specialty in its own right that requires three years of residency training. I don't think you can claim to be the equivalent to an FP just by virtue of having graduated med school or having completed an internship. If that were the case, FPs wouldn't need to do residency at all.

Also once you pass step three is receiving your license and your NPI number a formality? What does this process entail?

I don't have my NPI number yet. But as for unrestricted license, it varies by state. In PA, I had to fill out a bunch of paperwork, have two licensed docs vouch for my character and send money.

Good luck with everything.

 

[HolisticMed]

So are you saying that the ONLY way for a resident physician to moonlight in a private office and make money is to accept direct payment from patients? I cant help but believe there is SOME WAY for a resident to see patients and be reimbursed by insurance, I feel like I have heard about arrangements where this has occurred. But perhaps I am wrong.

This chiropractor is a provider for almost all private insurance companies including medicare. Unfortunately I dont see how his affiliations can possibly extend to me, even if I am listed as his employee.

😕

 

[sunlioness]

I've never heard of a resident moonlighting in a private office. But like I said, I'm in Pennsylvania and I'm also no expert on it. I've also never heard of a PGY-2 moonlighting in any setting other than inpatient doing general med/surg admission stuff, to be honest. There's a lot to know that a PGY-2 just wouldn't yet, especially in a specialty like PMR where your PGY-1 year is internal medicine and you don't do anything specialty-specific until PGY-2 anyway. I just can't imagine anyone wanting to pay to see a PGY-2 PM&R doc in a private practice working unsupervised. And even if they would, I don't see how you could ever expect to make enough to pay for malpractice (assuming you could find an insurer willing to insure a PGY-2 working unsupervised in a private practice), let alone pay for malpractice and make enough on top of that to have it be worth it. Malpractice can run upwards of $10,000/year. Like I said I'm no expert, but it just seems to be more trouble than it's worth.

 

[Winged Scapula]

So are you saying that the ONLY way for a resident physician to moonlight in a private office and make money is to accept direct payment from patients? I cant help but believe there is SOME WAY for a resident to see patients and be reimbursed by insurance, I feel like I have heard about arrangements where this has occurred. But perhaps I am wrong.

I have heard about it with Chief residents in some specialties who are BE and are thereby able to bill for their services. Obviously we are not experts in this situation, but I really recommend you simply as Physician Reps for some of the big insurance companies in your area as they will be the most knowledgeable as to whether or not they will insure you.

Like sunlioness, I cannot imagine you will be able to find a company to insure you and to make enough money to cover your malpractice.

This chiropractor is a provider for almost all private insurance companies including medicare. Unfortunately I dont see how his affiliations can possibly extend to me, even if I am listed as his employee.

😕

It cannot. If you see patients by yourself you have to be a provider who is contracted with the insurance companies.

Again, I agree with sunlionness, it sounds like too much work for little return. You *might* be able to get them to pay you for analysing EMGs, although I do not know what the requirements are to be able to legally do so.