Physician Reimbursement for Dummies

[HereWeGo21]

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Hello,
Pre-med here wondering exactly how physicians are reimbursed.

It sounds like specialists receive patients from the hospital administration according to availability, aka the neurosurgeon with the fewest current patients gets the next one admitted to the hospital.

At this point, how does the physician secure his reimbursement? Does he negotiate directly with the patient or the patient's insurance company? Or is he simply paid by the hospital (whether that be per patient, or per episode, or per service), assuming that the hospital has already negotiated with the insurance company?

On that note, what percentage of hospitals simply pay salaries? Among those that do pay salaries, do those hospitals tend to receive reimbursement from insurance companies based on capitation, episode of care or service? Among those patients that pay salaries, how many offer bonuses for quality care?

Thanks for everything!

 

[armybound]

Too many variables here for a simple, straightforward answer.

The first question you have to ask is if it's private practice or academic. Even within those, it varies widely.

I don't know if the data you're asking for are readily accessible.

 

[HereWeGo21]

Too many variables here for a simple, straightforward answer.

The first question you have to ask is if it's private practice or academic. Even within those, it varies widely.

I don't know if the data you're asking for are readily accessible.

I was asking about private, academic teaching hospitals. Sorry for the non-specificity.
If you don't know the overall answer, I'd still appreciate hearing how each one of you gets paid.

 

[armybound]

There's just a huge variety. Every practice could be different.

For a procedure-based practice, the physician bills for the procedure. The insurer will pay whatever they offer to pay for the surgeon, and the hospital will bill separately for supplies, OR time, etc. So in this case the physician would make the physician's fee that is paid by insurance. If this is a private practice group, they might pool those reimbursements and divvy them up based on however it is they decided to divvy them up, either you get what you get reimbursed for or you get a set salary or you get a certain percentage of overall reimbursements, etc.

Other practices (academia) might not receive their pay from insurance reimbursement. All money might be collected by the hospital/university on the physician's behalf and the physician could be offered a flat salary.. or they could be offered a flat salary plus extra based on their billing, RVUs, reimbursements, etc. That will vary widely.

So basically insurance is billed and pays for a procedure and the money either goes to the physician or their employer who sets their salary.

 

[HereWeGo21]

Great, thanks. I'm a little confused though, as this article says that only a small amount of academic hospitals pay salaries. So how are physicians usually reimbursed--is it per service?

In any case, what I'm gathering is that physicians at academic institutions don't handle insurance and reimbursement; the hospital administration does that for them.

 

[armybound]

Again, it widely varies. I would guess that the vast majority of non-private practices pay their physicians based on productivity -- the more you work, the more you bill, the more you're reimbursed, the more you earn.

One chair I know at a semi-private academic facility calculates all of his attending's RVUs in a year and sets their pay based on that. If they do more cases, they make more money. If their productivity decreases, they get paid less. It's not an exact 1:1 based on how much they're reimbursed by insurance.

 

[styphon]

I'll give this a shot: a variety of payment models exist regardless of hospital/group practice. Considering solo practice Or small group throws on a lot more.

Sticking to the larger groups/hospital based models.

Some are straight salaried - you work a fixed number of hours or see a certai number of patients/cases and that's that.

Another is the fading "pay for performance" p4p model. You are paid based on either the number of pts/procedures or a complexity based system(rvus). Another way to do this is a fixed amount of percent to you from "accounts billable" or "accounts collected".

A third way is a hybrid model. You get a base salary, and if you go above agreed upon parameters (hours or patients or amt billed or rvu units per unit of time) you get a bonus or switch to a p4p model. Hopefully this will be the future, but I am doubtful.

If you are in a large group or hospital - they have fixed prices with various insurance companies based on individual negotiations. This is where large systems help - they have the clout to stop insurance companies from abusing them or just not paying (very common for small hospitals, large insurance companies will just refuse to pay out).