PMR2008

PM&R
Aug 17, 2007
720
203
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  1. Attending Physician
I get a number of PM's regarding subacute/SNF rehab. There are a lot of misconceptions regarding the role physiatrists have in this practice setting. Working in the subacute setting was highly discouraged by my program director during residency even though quite a few of our attending had subacute side gigs. Unfortunately even now most residents do not get exposure during training. I wanted to make myself available to hopefully answer any questions people might have.

  1. What is subacute/ SNF rehab?
    Over the past decade and more intensely over the past 7 years, there has been a steady decline of patients being approved for Inpatient Rehab Facility (IRF) stays by Medicare. Through payer regulatory changes and certain determinations, these patients who would have been approved for IRF stays are now being discharged to Skilled Nursing Facilities (SNF). As of 2014, there were 339,000 beneficiaries in IRF vs 1.7 million in SNFs. Rehabilitation in the SNF environment is rapidly emerging as the predominant level of post-acute rehabilitation care in the United States. More patients will receive their rehabilitation in a SNF today than in an IRF—and the trend is likely to continue! Physiatrists have worked in the subacute environment since the 80’s but our involvement in this level of care is now more important than ever.
  2. Why did you decide to work in this setting?
    I was fortunate enough to complete my residency at a hospital with an attached SNF unit. As residents, we rounded on patients and covered them during call. The hospital also had a dedicated subacute rotation where residents spent time with the Attending Physicians learning firsthand how to provide care for patients in this setting. Most of our teaching attendings balanced an acute, SNF, and outpatient practice. Initially my interests were aligned within sports medicine, however, I quickly realized that a more balanced practice going forward would be the best answer.
  3. How is it different from acute rehab and outpatient?
    In a subacute setting, I work as a consultant in a team model where a primary care physician and I co-manage patient care. The types of patients can vary depending on the facility but most often I provide rehab and pain management for patients undergoing therapy. Patient mix is approximately 30-40% orthopedic, 15-20% neuro and the rest are cancer and cardiopulmonary rehab patients. The vast majority of issues I am managing are ‘bread and butter’ rehab including spasticity, pain, bowel/bladder, neuropathy, and amputee care, etc. I will also occasionally perform bedside joint injections. The primary care physician manages all other medical issues and will take call.
  4. How often are the patients seen?
    As per the AAPM&R position statement on a physiatrist’s role in skilled nursing facility, “in the ideal situation, a physiatrist in a SNF setting will serve in a consulting or co-treating physician role and visit the patient two to three times a week depending on the needs of the patient” (June 2016). As the length of stays are declining, sometimes the frequency increases to 3 times a week with the goal of leading to greater functional gains by the patient and cost saving to the health care system.
  5. What is the typical work schedule?
    I work 4 days a week about 8 hours a day. In my capacity as a consultant, I do not work on weekends or take call. Typically, I am able to see approximately twenty follow-up and five new patients a day. I also have an outpatient sports/spine practice one day a week and a medical legal practice.
  6. How did you start your practice?
    I had the opportunity to start the practice myself but I was concerned with stability and future Medicare regulations. I ended up joining a company as an independent contractor. The company provides managerial services for my practice. Initially one of my main concerns was stability but given that my overhead is very low, I am able to take home most of what I earn and have tremendous flexibility to create a work-life balance. I have the ability to create my own schedule, as well as implement changes and improvements to my practice and routine as needed. This type of work can be done on a full-time basis or as an addition to your current form of practice.
  7. What is the future of SNF rehab and is this a practice setting you feel is sustainable into the near future?
    The medical landscape has changed drastically since I began practicing in the SNF rehab setting 7 years ago. The changes in effect have led to increased focus on providing quality care, reducing readmissions to the hospitals and reducing cost. Physiatrists are well positioned as the ideal specialists to facilitate these objectives by providing continuing care of the patients during various stages of recovery.
  8. Do you find the work rewarding? I am extremely fortunate to work in the SNF rehab space. I believe I make a difference in the lives of my patients every day. I have the opportunity to provide outcome-oriented care, lead a team, and assist with cost saving while continuing to strive for optimal patient care. I am able to set goals, which correspond with the patient and their family’s needs. My focus is on eliminating barriers that impede transition from facility to home or a more home-like environment. I am also able to practice general physiatry without the pressures that come along with being an employee in a large scale medical practice or hospital.
 
May 16, 2015
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Is that pay just from your SNF work or is that also including the sports and spine outpatient?
 
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May 16, 2015
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Just SNF. 6-8 hours of work a day, no call and no weekends.

Wow that's actually amazing pay for those hours. And you're able to do a day of sports and spine clinic on top of that to increase those earnings? Haven't heard much about people doing SNF consults, but that might be on my radar now. Thanks for the information!
 
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PMR2018

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Sep 23, 2017
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Wow that's actually amazing pay for those hours. And you're able to do a day of sports and spine clinic on top of that to increase those earnings? Haven't heard much about people doing SNF consults, but that might be on my radar now. Thanks for the information!
Things move at a different speed and intensity at a SNF a lot of the time. You have to be okay with that which can be very frustrating to some people.
 

PMR2008

PM&R
Aug 17, 2007
720
203
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Things move at a different speed and intensity at a SNF a lot of the time. You have to be okay with that which can be very frustrating to some people.

Agree with you. But the practice is setup to suit your own style. It is not very organized and the nursing care in the SNF setting is subpar but the patients and the issues that you help them with are similar.
 
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castalmond

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Jan 31, 2012
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Thanks for the post - I had a few questions:
What percentage of collections does the company take?
Do you use a template, scribe, or other program for documentation?
What level do you bill for each encounter, if you are seeing 25+ patients a day?
 

PMR2008

PM&R
Aug 17, 2007
720
203
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  1. Attending Physician
Percentage of collection is based on part-time/full-time, seniority, market, company etc. Can range from 60% to 75%.
Templates + scribe. Sometimes dragon dictation to supplement.
Level of encounter is based on what I am doing for the patient. If prescribing meds than moderate while routine visit would be a low. I am very involved with rehab and med management.
 
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castalmond

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Jan 31, 2012
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Interesting, thanks. Sounds like the SNF staffing company takes 25-40%, which sounds ridiculously high when considering there is no overhead besides billing...
 

PMR2008

PM&R
Aug 17, 2007
720
203
Status
  1. Attending Physician
Not true. The overhead includes credentialing, marketing, full time admin support(phone calls, faxes), compliance, templates, billing apps, online portals-webinars, education, ongoing physician support, practice expansion, assisting in hiring midlevels, billing etc
What percentage of your collection as a hospital employee do you get to keep? Also what do you think is the average overhead in an outpatient clinic?
I agree that is sounds like a lot but there is power in numbers. If you want I can elaborate further.
 
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Not true. The overhead includes credentialing, marketing, full time admin support(phone calls, faxes), compliance, templates, billing apps, online portals-webinars, education, ongoing physician support, practice expansion, assisting in hiring midlevels, billing etc
What percentage of your collection as a hospital employee do you get to keep? Also what do you think is the average overhead in an outpatient clinic?
I agree that is sounds like a lot but there is power in numbers. If you want I can elaborate further.

Your lifestyle and salary both sound great (better than the majority of rehab physicians). But it does seem to me that your overhead High. My billers cut is 6%, and I am paid a director stipend. I pay my own malpractice insurance, but otherwise minimal overhead for me in an acute rehab unit.

Like I said, your lifestyle and salary are great. And maybe it’s a common thing for those doing consults at SNFs to have to give a big cut to the SNF facility. I don’t know much about SNF.

It’s great you started this thread-IPR is already losing so much interest (there are so many open positions, and even more filled positions are filled by non-PM&R), and my guess is interest in SNF is even lower. I think residents underestimate how nice of a life and income you can have by doing inpatient/SNF and how much they can make (and how much more you make when your not an employee)
 
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PMR2008

PM&R
Aug 17, 2007
720
203
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  1. Attending Physician
Agree with a lot of the points you have made. I just had a conversation with a physician this morning from the east cost. He has practiced for 15+ years. Works in the inpatient rehab setting with a clinic. He told me his billing last year was 1.7, collection was 900k while his take home was 200k. He told me he has asked for a production based raise for years without luck. He is planning on doing subacute now. Also they hired 50 new admin over the past year while they lost 2 physiatrists and they have not filled the positions for 3 years.
One of the best comments this physician made to me was that one of the reasons he has burned out is that he is only taking home 25% of his collection.

I have friends of mine who have nice gigs doing inpatient rehab. They are 1099, get medical director stipends, cover medium sized units and have internal medicine coverage. They also cover SNF's with PA/NP's. With that kind of setup making 650k+ a year is not very difficult.

Regardless of the money and the financial freedom (better chance to retire early) it gets you, it is the patient care. There is a stigma out there specially from the academic physiatrists that subacute work is 'dirty' or 'subpar'. The patients and conditions I am treating in the subacute setting are the same I was treating as a resident 10 years ago. If I get to make money while providing the same care I don't have a problem with that.

The only reason for my original post was to raise awareness and to address the questions I am asked privately all the time. The interest in SNF work has increased dramatically over the past few years as the awareness has improved.
 
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Agree with a lot of the points you have made. I just had a conversation with a physician this morning from the east cost. He has practiced for 15+ years. Works in the inpatient rehab setting with a clinic. He told me his billing last year was 1.7, collection was 900k while his take home was 200k. He told me he has asked for a production based raise for years without luck. He is planning on doing subacute now. Also they hired 50 new admin over the past year while they lost 2 physiatrists and they have not filled the positions for 3 years.
One of the best comments this physician made to me was that one of the reasons he has burned out is that he is only taking home 25% of his collection.

I have friends of mine who have nice gigs doing inpatient rehab. They are 1099, get medical director stipends, cover medium sized units and have internal medicine coverage. They also cover SNF's with PA/NP's. With that kind of setup making 650k+ a year is not very difficult.

Regardless of the money and the financial freedom (better chance to retire early) it gets you, it is the patient care. There is a stigma out there specially from the academic physiatrists that subacute work is 'dirty' or 'subpar'. The patients and conditions I am treating in the subacute setting are the same I was treating as a resident 10 years ago. If I get to make money while providing the same care I don't have a problem with that.

The only reason for my original post was to raise awareness and to address the questions I am asked privately all the time. The interest in SNF work has increased dramatically over the past few years as the awareness has improved.

That is an insane amount of collections! I don’t know how I’d stay alive if I was working enough to bring in that kind of collections. I’d have to see about 25 pts/day every day (no days off) to collect that amount (not including director stipend, but that’s not included in collections)

More insane is if that physician brought in $900k in patient billings, that they only got paid $200k. If I bring in 900k, I keep 900k (minus biller fees, of course). I’d also be retiring much earlier...
 
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PMR2008

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The doc I talked to is seeing 30+ patients a day. I think about 20+ inpatient and doing a lot of botox procedures etc. I have heard similar numbers for collection from other docs. The take home is ridiculously low in this case.
 
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The doc I talked to is seeing 30+ patients a day. I think about 20+ inpatient and doing a lot of botox procedures etc. I have heard similar numbers for collection from other docs. The take home is ridiculously low in this case.

That is crazy. I don’t know how I could see 30 patients/day, do a good job, and see my family. I have a hard time when I cover for my partner and see 18-25/day and have to cover weekends and call 24/7.

VA inpatient docs see 8-14 and get paid as much as the doctor you mention. I would have quit within weeks if I were in his/her situation.
 

castalmond

7+ Year Member
Jan 31, 2012
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Not true. The overhead includes credentialing, marketing, full time admin support(phone calls, faxes), compliance, templates, billing apps, online portals-webinars, education, ongoing physician support, practice expansion, assisting in hiring midlevels, billing etc
What percentage of your collection as a hospital employee do you get to keep? Also what do you think is the average overhead in an outpatient clinic?
I agree that is sounds like a lot but there is power in numbers. If you want I can elaborate further.

The 6% of collections that goes to the billing company typically covers billing apps, credentialing, and compliance. Not sure why practice expansion or hiring midlevels is part of the equation - you have a limited amount of time per day, therefore can only see a certain number of patients. The SNF staffing company expanding only brings in more money to the staffing company, not you.

You cannot compare overhead in an outpatient clinic to overhead in a SNF setting - for outpatient, you need to hire front office staff, pay rent/lease a building, and pay for EMR. These are provided by the SNF itself, and it is in the SNF's best interest to keep their beds full. Either way you look at it, the SNF staffing company is taking a cut of your earnings. Perhaps that cut is worth the convenience to some people... agree to disagree
 

PMR2008

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Aug 17, 2007
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Just a few things I want to bring up regarding your comments.
I have an independent clinic and I am well aware of overhead costs. I do have to pay rent, purchase supplies, pay my employees/taxes, accountant, insurance, EMR, computers, random things breaking, marketing etc etc. My billing company for clinic charges less than 6% but they do not provide an app. They do however as you mentioned cover credentialing and compliance etc. But as a solo practitioner, I don't have a lot of leverage negotiating with insurance companies. Also it is exceedingly difficult to run a solo practice due to multiple reasons. My overhead is about 30% for the clinic but the work I put in is more than what I have to do for SNF. Running a non opiate clinic I have to constantly market for new patients.
The EMR is not necessarily provided by the facility. Some SNF staffing companies have their own proprietary EMRs that communicate with the SNF EMRs. I could have saved 10% or maybe a little more a year if I did SNF work myself but I know that once I had an audit and as ownership and the regulations have changed being part of a larger group has certainly helped me. Buy YMMV.
Everyone takes a cut of your earning. It just depends on if you are satisfied with that it is for and if it helps you grown.
 
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digitoad8

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Aug 14, 2014
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I am graduating residency next year, and am interested in doing SNF consults. I don’t have experience working in a SNF, and it was also kind of looked down on in my residency program, so I don’t really have any mentors to ask about this area. What company did you join as a consultant? Do they assist in finding SNFs for you or how did you find SNFs to start consulting work and set up your practice? Thanks
 
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PMR2008

PM&R
Aug 17, 2007
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I am graduating residency next year, and am interested in doing SNF consults. I don’t have experience working in a SNF, and it was also kind of looked down on in my residency program, so I don’t really have any mentors to ask about this area. What company did you join as a consultant? Do they assist in finding SNFs for you or how did you find SNFs to start consulting work and set up your practice? Thanks
feel free to PM me. I can guide you.
 
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Piebaldi

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feel free to PM me. I can guide you.

PMR2008, out of curiosity, what has been your experience in terms of this viral epidemic affecting SNF work? I was thinking of doing some part time coverage as I go through my fellowship, but thinking it might be somewhat battered too particularly given how vulnerable NH patients are?
 
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PMR2008

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The patients are still there. I just had to switch to 100% telemedicine. It has gone reasonably well if the facility cooperates and helps. Working as a contractor for a bigger group has helped implement templates, G codes, contracts etc. Good luck trying to convince a new facility to have you round at this moment. That is the last thing on their mind.
 

Piebaldi

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The patients are still there. I just had to switch to 100% telemedicine. It has gone reasonably well if the facility cooperates and helps. Working as a contractor for a bigger group has helped implement templates, G codes, contracts etc. Good luck trying to convince a new facility to have you round at this moment. That is the last thing on their mind.

Yeah I figured as much. Are your patients still doing t herapy? And how do you do telemedicine with elderly patients in SNFS?
 
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PMR2008

PM&R
Aug 17, 2007
720
203
Status
  1. Attending Physician
Telemedicine is challenging for the elderly population regardless of setting. My friends in outpatient practices have the same issues. It takes some staff training and patience. The patients seem to get used to it pretty quickly. They appreciate us checking in on them and understand why we are not able to come in person. For some facilities we have contracted with staff to help us during off hours. For patients with iphones it is pretty easy to do facetime. Sometimes I have to use the therapist to assist. No simple and easy one-size-fit-all solution.
 

ieatpaste37

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Apr 22, 2006
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I've been doing pain management/outpatient msk as my career. I've never done SNF work. Given the covid, I still do some telemedicine but not much. Nobody goes except for opioid refills.

I got in touch with a physiatrist that always used to annoy me and others about doing snf work. He is a "ceo" of a snf company. I have never done this type of work before until 3 weeks ago. I read over the templates and everything that his company gives which is pretty straightforward. How is this job NOT medicare fraud? What do SNF physiatrist actually do? I go in one day a week and another physiatrist that works for this person goes in another day of the week. She (the other physiatrist) just writes diagnoses in her note? She does not even write like a plan. She sees apparently like 45 patients a day. I ended up seeing 25 patients a day but I could probably see 100 patients a day if I made my notes like her. I do not even know if she talks to the patients. Also, everybody looks at you like "who are you?" I ask the PT "any issues with any patients?" and the PT was like "no, we are good." for 2 weeks in a row.
Apparently you do not put in any orders either. There is an internist that the nurses and even therapists go to for orders and recs. How are you even a doctor if you do not put in orders or get pages from nursing staff?
God bless these physiatrists that do this type of work and more power to you for doing this as a career. I have zero idea how insurance reimburses for this. The guy I work for gives me 75% collections which I think is a low percentage given there is absolutely no overhead except for billing.
 

PMR2008

PM&R
Aug 17, 2007
720
203
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  1. Attending Physician
Physiatrist who practice the way she is practicing give all of us a bad name. Their are physiatrist who practice in all sorts of settings who have given our specialty a bad name. I know of plenty of cases of physiatrist running 'pill mills' ' injection mills' and 'EMG mills'. You can not make blanket statements like the ones you have made.
I have been doing SNF work full time for 8 years now. The primary care, therapist, social worker all depend on me to for all rehab/pain/msk/neuro issues. I put in all my own orders. I order imaging, labs etc. I help set discharge dates and plans. I perform hundreds of bedside injections a year. The issues you are having are probably more based on the company you are working for and the relationship they have with the SNF. If you owner is giving you 75% of the collection and not investing the money back into the company than that is concerning. The company I work for developed its own EMR that communicates with the facility EMR, we have staff handling calls, marketing, training, internal audits etc. I am not trying to convince anyone to join a group but if you do make sure they are running an ethical practice and are investing the money back into the practice.
 
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Piebaldi

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Physiatrist who practice the way she is practicing give all of us a bad name. Their are physiatrist who practice in all sorts of settings who have given our specialty a bad name. I know of plenty of cases of physiatrist running 'pill mills' ' injection mills' and 'EMG mills'. You can not make blanket statements like the ones you have made.
I have been doing SNF work full time for 8 years now. The primary care, therapist, social worker all depend on me to for all rehab/pain/msk/neuro issues. I put in all my own orders. I order imaging, labs etc. I help set discharge dates and plans. I perform hundreds of bedside injections a year. The issues you are having are probably more based on the company you are working for and the relationship they have with the SNF. If you owner is giving you 75% of the collection and not investing the money back into the company than that is concerning. The company I work for developed its own EMR that communicates with the facility EMR, we have staff handling calls, marketing, training, internal audits etc. I am not trying to convince anyone to join a group but if you do make sure they are running an ethical practice and are investing the money back into the practice.

Going to PM you - have some questions for you.
 
I have heard very similar stories from 3-4 different physiatrists. I know there has to be more to SNF work as PMR2008 is referring to, but from the limited exposure I have had, it seems like a racket. No orders, a handful of knee and shoulder injections, and no call for any patients you are helping to manage. Are you going to IDT meetings? I am not sure what exactly you are doing.


I've been doing pain management/outpatient msk as my career. I've never done SNF work. Given the covid, I still do some telemedicine but not much. Nobody goes except for opioid refills.

I got in touch with a physiatrist that always used to annoy me and others about doing snf work. He is a "ceo" of a snf company. I have never done this type of work before until 3 weeks ago. I read over the templates and everything that his company gives which is pretty straightforward. How is this job NOT medicare fraud? What do SNF physiatrist actually do? I go in one day a week and another physiatrist that works for this person goes in another day of the week. She (the other physiatrist) just writes diagnoses in her note? She does not even write like a plan. She sees apparently like 45 patients a day. I ended up seeing 25 patients a day but I could probably see 100 patients a day if I made my notes like her. I do not even know if she talks to the patients. Also, everybody looks at you like "who are you?" I ask the PT "any issues with any patients?" and the PT was like "no, we are good." for 2 weeks in a row.
Apparently you do not put in any orders either. There is an internist that the nurses and even therapists go to for orders and recs. How are you even a doctor if you do not put in orders or get pages from nursing staff?
God bless these physiatrists that do this type of work and more power to you for doing this as a career. I have zero idea how insurance reimburses for this. The guy I work for gives me 75% collections which I think is a low percentage given there is absolutely no overhead except for billing.
 
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PMR2008

PM&R
Aug 17, 2007
720
203
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  1. Attending Physician
I have heard very similar stories from 3-4 different physiatrists. I know there has to be more to SNF work as PMR2008 is referring to, but from the limited exposure I have had, it seems like a racket. No orders, a handful of knee and shoulder injections, and no call for any patients you are helping to manage. Are you going to IDT meetings? I am not sure what exactly you are doing.

I am not going to lie. It is as easy to create a SNF racket. Just like I have seen physiatrist create Pill Mill and Stem Cell rackets. I am a career SNF'ist. Everyone Physiatrist in our company follows clinical protocols. We attend IDT meetings, do peer to peer, create fall prevention and ortho protocols etc. We are contracted with national companies, ACO's, hospital systems to create value. Most definitely some Physiatrist will use SNF work to fill their pockets. This certainly does not help improve the branding of Physiatry.
 
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I am glad to hear this perspective. Thank you for sharing.

I am not going to lie. It is as easy to create a SNF racket. Just like I have seen physiatrist create Pill Mill and Stem Cell rackets. I am a career SNF'ist. Everyone Physiatrist in our company follows clinical protocols. We attend IDT meetings, do peer to peer, create fall prevention and ortho protocols etc. We are contracted with national companies, ACO's, hospital systems to create value. Most definitely some Physiatrist will use SNF work to fill their pockets. This certainly does not help improve the branding of Physiatry.
 
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Piebaldi

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I am not going to lie. It is as easy to create a SNF racket. Just like I have seen physiatrist create Pill Mill and Stem Cell rackets. I am a career SNF'ist. Everyone Physiatrist in our company follows clinical protocols. We attend IDT meetings, do peer to peer, create fall prevention and ortho protocols etc. We are contracted with national companies, ACO's, hospital systems to create value. Most definitely some Physiatrist will use SNF work to fill their pockets. This certainly does not help improve the branding of Physiatry.

I'd agree.
 

Hussein Baradia

PMR doc
Nov 18, 2020
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I've been doing pain management/outpatient msk as my career. I've never done SNF work. Given the covid, I still do some telemedicine but not much. Nobody goes except for opioid refills.

I got in touch with a physiatrist that always used to annoy me and others about doing snf work. He is a "ceo" of a snf company. I have never done this type of work before until 3 weeks ago. I read over the templates and everything that his company gives which is pretty straightforward. How is this job NOT medicare fraud? What do SNF physiatrist actually do? I go in one day a week and another physiatrist that works for this person goes in another day of the week. She (the other physiatrist) just writes diagnoses in her note? She does not even write like a plan. She sees apparently like 45 patients a day. I ended up seeing 25 patients a day but I could probably see 100 patients a day if I made my notes like her. I do not even know if she talks to the patients. Also, everybody looks at you like "who are you?" I ask the PT "any issues with any patients?" and the PT was like "no, we are good." for 2 weeks in a row.
Apparently you do not put in any orders either. There is an internist that the nurses and even therapists go to for orders and recs. How are you even a doctor if you do not put in orders or get pages from nursing staff?
God bless these physiatrists that do this type of work and more power to you for doing this as a career. I have zero idea how insurance reimburses for this. The guy I work for gives me 75% collections which I think is a low percentage given there is absolutely no overhead except for billing.
I agree that this is Medicare fraud. I just started at a SNF too and don't feel that a PM&R doc would be adding any value. It is a push by these companies that get an EMR and hire people to recruit physiatrists' to go out there and see as many patient so they can keep their 40% cut. Honestly I think we are being highly unethical and this is how we lose our priviledges when we try to be greedy. All the contributors to this thread see 25-30 patients and for the most part do not make any recommendations besides continue with PT/OT and speech. One thing that surprises me is that they can come out to this thread and glorify the job they do and collect huge sums of money. It is only a matter of time when medicare comes out with a stick to punish not only these people but also physiatrists in general.
 

PMR2008

PM&R
Aug 17, 2007
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You have every right to feel that way. But making general statements like " All the contributors to this thread see 25-30 patients and for the most part do not make any recommendations besides continue with PT/OT and speech. One thing that surprises me is that they can come out to this thread and glorify the job they do and collect huge sums of money." is unfair.
I do not want to lecture you on what exactly I do for the patients because I have mentioned it many time before. You are probably working for the wrong group, without adequate support and mentorship or you don't know how subacute consults work. Close to a 1,000 Physiatrists( I am happy to share the data) are currently working in the subacute setting. Would you say they are all committing fraud?
 
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You have every right to feel that way. But making general statements like " All the contributors to this thread see 25-30 patients and for the most part do not make any recommendations besides continue with PT/OT and speech. One thing that surprises me is that they can come out to this thread and glorify the job they do and collect huge sums of money." is unfair.
I do not want to lecture you on what exactly I do for the patients because I have mentioned it many time before. You are probably working for the wrong group, without adequate support and mentorship or you don't know how subacute consults work. Close to a 1,000 Physiatrists( I am happy to share the data) are currently working in the subacute setting. Would you say they are all committing fraud?

It sounds like you are actually providing ethical, valuable care rather similar to in an IRF setting in your practice so I agree that we can't generalize all SNF physiatrists like that. I think the importance of right support and mentorship like you said cannot be overemphasized.

From anecdotal experiences including my own, it does seem the shady models mentioned above are much more common. I didn't feel like I was doing anything during my brief stint and and I was basically making social visits from room to room. The SNF made it clear they don't like me ordering anything. My acquaintances/friends in SNF tell me that they spend 2 hours each day seeing 25-40 patients (that's 3-4 minutes per patient not accounting for walking between rooms and talking to any nurses/PT on the way?), copy paste "continue PT/OT", and go home. These are mostly new grads and I have a hard time believing that's just them being very efficient unless they have multiple clones of themselves.
 
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It sounds like you are actually providing ethical, valuable care rather similar to in an IRF setting in your practice so I agree that we can't generalize all SNF physiatrists like that. I think the importance of right support and mentorship like you said cannot be overemphasized.

From anecdotal experiences including my own, it does seem the shady models mentioned above are much more common. I didn't feel like I was doing anything during my brief stint and and I was basically make social visits from room to room. The SNF made it clear they don't like me ordering anything. My acquaintances/friends in SNF tell me that they spend 2 hours each day seeing 25-40 patients (that's 3-4 minutes per patient not accounting for walking between rooms and talking to any nurses/PT on the way?), copy paste "continue PT/OT", and go home. These are mostly new grads and I have a hard time believing that's just them being very efficient unless they have multiple clones of themselves.

Why is it wrong for rounding to be so brief? To be honest, the therapists and nurses are in a better role and position to notice any musculoskeletal issues and/or rehab barriers—they actually work with the patients on ADL's and functional tasks. If that can be accomplished by stopping by and asking the director of rehab "Are there any specific and/or pressing issues to address today for any patients?" is that wrong?

And if you're arguing that we should be doing thorough physical exams on each patient regularly, I encourage you to read this tweet thread:


"framing the physical exam as a critical component of diagnostic reasoning. Each maneuver = a diagnostic test. For each: what’s the indication, what specifically are you trying to detect (more than just “abnormal”), & how will the result change management."
 
Dec 9, 2019
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Why is it wrong for rounding to be so brief? To be honest, the therapists and nurses are in a better role and position to notice any musculoskeletal issues and/or rehab barriers—they actually work with the patients on ADL's and functional tasks. If that can be accomplished by stopping by and asking the director of rehab "Are there any specific and/or pressing issues to address today for any patients?" is that wrong?

And if you're arguing that we should be doing thorough physical exams on each patient regularly, I encourage you to read this tweet thread:


"framing the physical exam as a critical component of diagnostic reasoning. Each maneuver = a diagnostic test. For each: what’s the indication, what specifically are you trying to detect (more than just “abnormal”), & how will the result change management."

Nope, never said you need thorough physical exam on every patient every visit. I also specified that I don't mean to generalize SNF work as it looks like there are physiatrists in SNF who provide valuable care, so please don't feel like I'm attacking all physiatrists personally. Like I said, people I know in SNF run a "say hi and bill medicare" type of practice, and it is something I felt like I was boxed into doing during my own short experience doing this work. Yours is likely different from this and similar to PMR2008's practices which is great. It just feels rather rare anecdotally, which of course I admit could just be from that I haven't seen enough.

To quote PMR2008 above "The primary care, therapist, social worker all depend on me to for all rehab/pain/msk/neuro issues. I put in all my own orders. I order imaging, labs etc. I help set discharge dates and plans. I perform hundreds of bedside injections a year." - whether this is achievable in 3 minutes per patient seems like something we can agree to disagree on.
 
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Nope, never said you need thorough physical exam on every patient every visit. I also specified that I don't mean to generalize SNF work as it looks like there are physiatrists in SNF who provide valuable care, so please don't feel like I'm attacking all physiatrists personally. Like I said, people I know in SNF run a "say hi and bill medicare" type of practice, and it is something I felt like I was boxed into doing during my own short experience doing this work. Yours is likely different from this and similar to PMR2008's practices which is great. It just feels rather rare anecdotally, which of course I admit could just be from that I haven't seen enough.

To quote PMR2008 above "The primary care, therapist, social worker all depend on me to for all rehab/pain/msk/neuro issues. I put in all my own orders. I order imaging, labs etc. I help set discharge dates and plans. I perform hundreds of bedside injections a year." - whether this is achievable in 3 minutes per patient seems like something we can agree to disagree on.

Sorry if I came off aggressive. I also put in my own orders, labs, imaging right now. I was actually asked to do this because the primary rounds on these patients very infrequently and takes a very long time to answer non-urgent pages. For those patients that require further work-up, new labs/imaging, bedside interventions, it does take me more than 3-4 minutes. The average may work out to 3-4 minutes per patient but in actuality—while many of the patients can be seen quickly (with documentation that is also very straightforward), maybe something like 5-8 out of 30 require more time.
 
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Does some of the "Hi -> bill Medicare" type of rounding partially enabled by the facilities themselves? Do they see the PM&R doc as more of a marketing thing ("Look, now we have a rehab doctor too!"). Also facilities that have historically had no PM&R presence might have a culture in their admin/nursing/therapy departments that don't like change and see a PM&R doc simply as an outsider.

Gotta admit, the schedule of a SNF-only doc sounds good, while I'm here waiting for my 4:45 new pain eval...
 

PMR2008

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Nope, never said you need thorough physical exam on every patient every visit. I also specified that I don't mean to generalize SNF work as it looks like there are physiatrists in SNF who provide valuable care, so please don't feel like I'm attacking all physiatrists personally. Like I said, people I know in SNF run a "say hi and bill medicare" type of practice, and it is something I felt like I was boxed into doing during my own short experience doing this work. Yours is likely different from this and similar to PMR2008's practices which is great. It just feels rather rare anecdotally, which of course I admit could just be from that I haven't seen enough.

To quote PMR2008 above "The primary care, therapist, social worker all depend on me to for all rehab/pain/msk/neuro issues. I put in all my own orders. I order imaging, labs etc. I help set discharge dates and plans. I perform hundreds of bedside injections a year." - whether this is achievable in 3 minutes per patient seems like something we can agree to disagree on.
I whole heartedly agree with you.
I personally know docs who regularly see 60-75 patients a day. I have never been able to see more than 30. Even my brief follow up visits are 5-7 minutes long. Plenty of time to discuss information I get from my team. I get to talk about therapy progress, labs, imaging prognosis, medication changes, discharge planning, further barriers and quick exam to see how ROM, strength, spasticity is changing.
The SNF setting can be a ideal environment to commit fraud. I know of a local primary doc and psychiatrist who used to show up at the facility and leave in 10 minutes. They used to bill for bill for patients without seeing them. Now the docs are in prison.
I am sure most of you know this already but fraud can be committed in any setting. Plenty of physiatrists are either in prison or have had their licenses taken away for billing epidurals when performing trigger point injections etc.
Other examples

Plenty of other ways. Frequent UDS, knee/back brace for everyone, $5000/stem-amnio cell injection, bilateral UE and LE EMG's on everyone, rounding on acute rehab patients 7 days a week, seeing nothing but out of network patients, all procedures in the ASC, bilateral TFESI series, p ....etc.

Even when seeing 25-30 patients a day you can make an excellent living working in the subacute setting.
 

PMR2008

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Also wanted to add another point. At least in the company I work at they have frequent third party audits to make sure we are in compliance. I am still responsible for my own notes and billing but I feel better when I pass the third party audit. We do not tolerate physicians who do "Hi -> bill Medicare". The facilities partner with us specifically to improve outcomes, reduce length of stay, improve patient satisfaction and marketing. We have had Physicians who tired to game the system and they did not last long with us.
 
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I whole heartedly agree with you.
I personally know docs who regularly see 60-75 patients a day. I have never been able to see more than 30. Even my brief follow up visits are 5-7 minutes long. Plenty of time to discuss information I get from my team. I get to talk about therapy progress, labs, imaging prognosis, medication changes, discharge planning, further barriers and quick exam to see how ROM, strength, spasticity is changing.
The SNF setting can be a ideal environment to commit fraud. I know of a local primary doc and psychiatrist who used to show up at the facility and leave in 10 minutes. They used to bill for bill for patients without seeing them. Now the docs are in prison.
I am sure most of you know this already but fraud can be committed in any setting. Plenty of physiatrists are either in prison or have had their licenses taken away for billing epidurals when performing trigger point injections etc.
Other examples

Plenty of other ways. Frequent UDS, knee/back brace for everyone, $5000/stem-amnio cell injection, bilateral UE and LE EMG's on everyone, rounding on acute rehab patients 7 days a week, seeing nothing but out of network patients, all procedures in the ASC, bilateral TFESI series, p ....etc.

Even when seeing 25-30 patients a day you can make an excellent living working in the subacute setting.

60-75 per day!?!?!?

How often were the local primary doc and psychiatrist seeing the patients? Do you know how they got caught? I'm assuming they at least documented?
 

PMR2008

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I am sure you know or should know what comparative billing is. You are compared to other providers who bill the same code. If you are billing above that you will be audited. Once audited if you are not able to provide documentation and medical necessity it can lead to further investigation. Frequently these cases involve a whistleblower. They were caught after years of abusing the system.
 
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PMR2008

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You will always have outliers. I did an ortho rotation as a medical student and the surgeon saw 45-50 a day. You never want to be an outlier and if you are make sure your documentation is strong.
Coming out of fellowship I interviewed at a pain practice that saw 60/day. Come to find out they were closed down 2 years later lol.
 
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How are you going to post a link to a site that requires a subscription to view the whole page?


You will always have outliers. I did an ortho rotation as a medical student and the surgeon saw 45-50 a day. You never want to be an outlier and if you are make sure your documentation is strong.
Coming out of fellowship I interviewed at a pain practice that saw 60/day. Come to find out they were closed down 2 years later lol.
 
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How are you going to post a link to a site that requires a subscription to view the whole page?
This may be helpful:

Trends in initial visit billing frequency (nursing home): ~60% 99306, ~40% 99305 (the rest 99304)
Trends in subsequent code billing frequency (nursing home): ~45% 99308, 45% 99309 (the rest 99307, 993310)

The takeaway is that if you want to avoid an audit from CMS, avoid coding so many 99306 and 99309's that you stand out from your peers. Of course, if an audit is triggered, as long as your documentation can support your coding, then you're fine. However, most physicians would rather just avoid triggering that audit in the first place.
 
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I whole heartedly agree with you.
I personally know docs who regularly see 60-75 patients a day. I have never been able to see more than 30. Even my brief follow up visits are 5-7 minutes long. Plenty of time to discuss information I get from my team. I get to talk about therapy progress, labs, imaging prognosis, medication changes, discharge planning, further barriers and quick exam to see how ROM, strength, spasticity is changing.
The SNF setting can be a ideal environment to commit fraud. I know of a local primary doc and psychiatrist who used to show up at the facility and leave in 10 minutes. They used to bill for bill for patients without seeing them. Now the docs are in prison.
I am sure most of you know this already but fraud can be committed in any setting. Plenty of physiatrists are either in prison or have had their licenses taken away for billing epidurals when performing trigger point injections etc.
Other examples

Plenty of other ways. Frequent UDS, knee/back brace for everyone, $5000/stem-amnio cell injection, bilateral UE and LE EMG's on everyone, rounding on acute rehab patients 7 days a week, seeing nothing but out of network patients, all procedures in the ASC, bilateral TFESI series, p ....etc.

Even when seeing 25-30 patients a day you can make an excellent living working in the subacute setting.

I agree with most of what you said. But what is wrong with rounding on acute rehab patients 7 days per week? That was standard in my training across multiple programs. 3x is the minimum. Currently we round 6 days per week (no therapy on Sundays), but I think we could still easilly justify Sunday rounding due to issues with pain/bowel/bladder/etc.
 
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I'll also add that I've seen some documentation from my colleagues that seem really insufficient when trying to communicate medical complexity/necessity. Like any specialty/subspecialty/job, there will be incompetent, good, bad actors
 

PMR2008

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I agree with most of what you said. But what is wrong with rounding on acute rehab patients 7 days per week? That was standard in my training across multiple programs. 3x is the minimum. Currently we round 6 days per week (no therapy on Sundays), but I think we could still easilly justify Sunday rounding due to issues with pain/bowel/bladder/etc.
7 days a week rounding is absolutely fine. When medically justified. I have seen many scenarios when patients have IM coverage and Physiatry coverage. If you add them up a patient being seen 10-14 times a week can be excessive. Off course if the documentation/complexity demands it than it is fine.
I occasionally consult as a utilization reviewer and I have been able to justify many patients to be seen 7 days a week. We have 20+ Physiatrist in my group that cover IRF and we recommend 5 days a week and any additional coverage needs strong documentation (unstable condition, lab review, discharge planning, change in condition)
 
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7 days a week rounding is absolutely fine. When medically justified. I have seen many scenarios when patients have IM coverage and Physiatry coverage. If you add them up a patient being seen 10-14 times a week can be excessive. Off course if the documentation/complexity demands it than it is fine.
I occasionally consult as a utilization reviewer and I have been able to justify many patients to be seen 7 days a week. We have 20+ Physiatrist in my group that cover IRF and we recommend 5 days a week and any additional coverage needs strong documentation (unstable condition, lab review, discharge planning, change in condition)

Do your partners not round on the weekend or do they not see patients during the week?

I feels like there’s so much going on during the week I wouldn’t want to skip any of those days, but I sure wouldn’t mind taking the weekend off and covering call from home. Unfortunately hospital bylaws here state patients have to be seen by a physician every other week.
 

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