Thoughts on Job Offer?

[rjs2131]

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CAP - Outpatient position + q9-10 call coverage of inpatient unit (20 bed capacity - weekend rounding + phone call coverage during the week)
- Base - 265K guarantee, once wRVU threshold of 4000 wRVUs exceeded, pays ~$64/wRVU
- CME ~6K/year
- 4 weeks vacation (including sick days, CME, etc)
- 60-min news, 30-min follow-ups - clinic is open 8-5 M-F, have 1 hour or so of admin time/day to use at your discretion
- Non-compete that basically prevents you from working in the same city for 1 year after leaving

What else would you want to know? What seems reasonable/unreasonable?

 

[Stagg737]

When you say Q9-10 call, I'm assuming it's Q9-10 weeks? Also, for the phone coverage during the week is that just for overnight or all day?

This actually doesn't seem terrible if this were an adult position, but CAP seems like evals should be longer or base pay should be higher. What's insurance coverage like? Are the support and inpatient staff good? Also, the non-compete sucks.

 

[rjs2131]

When you say Q9-10 call, I'm assuming it's Q9-10 weeks? Also, for the phone coverage during the week is that just for overnight or all day?

This actually doesn't seem terrible if this were an adult position, but CAP seems like evals should be longer or base pay should be higher. What's insurance coverage like? Are the support and inpatient staff good? Also, the non-compete sucks.

Yeah - every 9-10 weeks or so. My understanding is phone coverage during the week for any after hours floor issues and then weekend rounding.
Insurance is a mix of medicaid and private. Seems like support staff are solid from what I can gather...agree about the non-compete!

 

[psychacad]

The noncompete is pretty bad. See if you can renegotiate. Can't practice in same city? Really?
4 weeks vacation INCLUDING CME and sick days?

What's the location? metro or rural?

I think it's OK, but I would attempt to negotiate the noncompete, and ask for higher pay for the call. Vacation sucks.

 

[comp1]

Ugh, that is not amazing in terms of benefits. It's okay in terms of pay, depending on where you live. Remember, you're in demand. Get that non-compete struck the heck out at the very least. I'm so glad that kind of stuff is illegal where I live.

 

[rjs2131]

So technically for non-compete it’s 20 miles from primary practice site but thats basically anywhere you’d want to work in this city (excluding your own PP in a neighboring city I guess).

Location is metro/desirable.

Would love more days off/no non-compete and will try and get that. What else would y’all negotiate for?

 

[Sushirolls]

I'm going to quote myself, and reference to previous thread:

Got a contract? Get a lawyer.

For the new grads, or the seasoned docs changing jobs, get a lawyer to review your contracts AND represent you. Most jobs are boiler plate templates, but even then I've combed over one such boiler plate and found few errors. In conjunction with a lawyer better language was drafted, additions...

forums.studentdoctor.net

 

[psychacad]

So technically for non-compete it’s 20 miles from primary practice site but thats basically anywhere you’d want to work in this city (excluding your own PP in a neighboring city I guess).

Location is metro/desirable.

Would love more days off/no non-compete and will try and get that. What else would y’all negotiate for?

Honestly vacation is a deal breaker for me. I've had 4 weeks vacation, 10 days sick leave and 3 days CME in residency, and that I think should be a minimum for a salaried attending. if you're planning on staying for more than a year, this is a recipe for burnout.

 

[Merovinge]

When you say 8-5 with 1 hour of admin, does that mean you have 8 hours clinical, 1 hour "admin" which would just be called lunch to anyone in a reasonable profession? 40 clinical hours with 60 min intake/30 min f/u is a really heavy CAP outpatient job. Many folks do 90-120 minute new patient evaluations and work 32 to maybe 36 clinical hours. If you take medicaid your practice will fill before you even open (with any amount of marketing) so expect a lot of phone calls, prior authorizations, requests from schools, etc with how many patients will be on your census. How good your nurse is will really make/break the job IMO.

3 weeks vacation 1 week CME is just gross, I guess if you hate traveling or spending time with friends that live in other cities that could be reasonable, but less than 6 weeks vacation +sick +CME is a real non-starter for me. If you plan on staying in the city, the non-compete is also completely undoable, you do not want to be forced into telepsych/locums for a year. I could conceive of a non-solicitiation taking it's place and be okay with that.

I would say FMV for 40 clinical hours plus some pretty painful call needing to go in and be woken up at night for inpatient harassment is bare minimum 300k, 350 in some locations. I know of many people in urban areas working 32 clinical hours/week making 270k+ without any call requirement in CAP for point of comparison.

 

[AD04]

With proper billing codes, you will more than exceed the base wRVU. If you're productive, you have potential of making $400k+ even with current numbers if you bill correctly. Are they using 2021 wRVU? Can you negotiate the $ / wRVU up? Can you have more vacation? (It's good to have the option to have more vacation but that doesn't mean you'll have to take them.) Agree with others regarding non-compete.

 

[dl2dp2]

Agree ^^^ Why is the salary so low. This job should pay 350k+

 

[rjs2131]

Appreciate all of the responses!

To clarify a few points - 1 hr admin/day is in addition to 1 hour of lunch time. So an 8-5 day would look more like ~7 clinical hours (~35 clinical hours/week if completely full).

The 265k seems to be more of a "base" until you meet that ~4000 RVU threshold - as @AD04 mentioned, it seems pretty easy to meet and exceed this if I'm billing 99213/99214 + 90833 for follow-ups and 99205/99204 + 90833 for news. Per my calculations, once full I should comfortably be in the ballpark of 300-350K for a year (and this is independent of the RVUs call will add). The only thing really preventing that is no-shows from what I can tell.

@Merovinge - which geographic location are you seeing 270k+ for CAP positions with 32 hrs/week and no call at all?

One thing I'm not really understanding here is how some of these bigger hospital systems/organizations can afford to pay $60-70/wRVU...if I'm billing 99213/99214+90833 for follow-ups this generates ~5-6 wRVUs/hour which is >$300/hour. Have they really negotiated rates significantly better than this with insurance companies? Or does this fall in the realm of "we make our money from other specialties and use a chunk of that to pay you"?

 

[splik]

One thing I'm not really understanding here is how some of these bigger hospital systems/organizations can afford to pay $60-70/wRVU...if I'm billing 99213/99214+90833 for follow-ups this generates ~5-6 wRVUs/hour which is >$300/hour. Have they really negotiated rates significantly better than this with insurance companies? Or does this fall in the realm of "we make our money from other specialties and use a chunk of that to pay you"?

many large hospital systems typically negotiate for insurance to pay 3x Medicare rates whereas solo practitioners can sometimes be lucky for insurance to pay even the Medicare rate. So yes they are making a big chunk of money though if they really accept Medicaid than this RVU conversion is very high, slightly below average if accepts commercial only.

 

[Merovinge]

Appreciate all of the responses!

To clarify a few points - 1 hr admin/day is in addition to 1 hour of lunch time. So an 8-5 day would look more like ~7 clinical hours (~35 clinical hours/week if completely full).

The 265k seems to be more of a "base" until you meet that ~4000 RVU threshold - as @AD04 mentioned, it seems pretty easy to meet and exceed this if I'm billing 99213/99214 + 90833 for follow-ups and 99205/99204 + 90833 for news. Per my calculations, once full I should comfortably be in the ballpark of 300-350K for a year (and this is independent of the RVUs call will add). The only thing really preventing that is no-shows from what I can tell.

@Merovinge - which geographic location are you seeing 270k+ for CAP positions with 32 hrs/week and no call at all?

One thing I'm not really understanding here is how some of these bigger hospital systems/organizations can afford to pay $60-70/wRVU...if I'm billing 99213/99214+90833 for follow-ups this generates ~5-6 wRVUs/hour which is >$300/hour. Have they really negotiated rates significantly better than this with insurance companies? Or does this fall in the realm of "we make our money from other specialties and use a chunk of that to pay you"?

Okay 35 hours/week is at least in the realm of reason, if not a bit high for my tastes.

Keep in mind no-show rates are going to be significant if you have a medicaid population, double booking is also really untenable IMO in psychiatry due to how long our appointments are. I have an exceptionally low no-show rate for being a medicaid practice at just below 10%, numbers from other people I have spoken to are easily in the 15-20% range.

Billing a 99205 +90833 would be news to be me for an intake, particularly in the 60 minute range, however 2x 99214 + 90833/ hour for f/u's is very doable with 2021 changes that were designed to increase outpatient RVU generation (both making 214 easier to hit and increasing it's RVUs). Keep in mind the people I know on current CAP outpatient jobs were all negotiated under the old E&M and you are entering a market that is supposed to generate additional RVUs. You can make 270k without call on 32 clinical hours in probably every single major metro, certainly in the Midwest, South, and West coasts I know people in such jobs.

Billing just north of $300/hour is not an unusual or absurd rate. Curious if you have ever tried to hire a lawyer or even a financial advisor with a bachelors degree and some letters after their name (decent ones are all >$300/hour).

I don't think the position itself is bad, better than some people post, but it's also nothing insane that people will be fighting you to have. Vacation + noncompete would be my biggest areas to negotiate if I felt like my support staff were good and I wanted the job.

 

[calvnandhobbs68]

Appreciate all of the responses!

To clarify a few points - 1 hr admin/day is in addition to 1 hour of lunch time. So an 8-5 day would look more like ~7 clinical hours (~35 clinical hours/week if completely full).

The 265k seems to be more of a "base" until you meet that ~4000 RVU threshold - as @AD04 mentioned, it seems pretty easy to meet and exceed this if I'm billing 99213/99214 + 90833 for follow-ups and 99205/99204 + 90833 for news. Per my calculations, once full I should comfortably be in the ballpark of 300-350K for a year (and this is independent of the RVUs call will add). The only thing really preventing that is no-shows from what I can tell.

@Merovinge - which geographic location are you seeing 270k+ for CAP positions with 32 hrs/week and no call at all?

One thing I'm not really understanding here is how some of these bigger hospital systems/organizations can afford to pay $60-70/wRVU...if I'm billing 99213/99214+90833 for follow-ups this generates ~5-6 wRVUs/hour which is >$300/hour. Have they really negotiated rates significantly better than this with insurance companies? Or does this fall in the realm of "we make our money from other specialties and use a chunk of that to pay you"?

Midwest have definitely seen outpatient 35 patient contact hours a week (so avg 70 patient encounters a week once full) that would hit 270K a year (numbers based on only billing average half the f/u with a 90833 add on), no call whatsoever, completely outpatient. Keep in mind that's based on only billing 50% of your contacts with any add on code (so I think people mix and match 20min f/u without add on code vs 30min f/u with add on codes).

@Merovinge is right, no shows for Medicaid tend to be pretty high due to the fact you can't charge no show fees (so the only penalty is really discharge after X no-shows which turns into a pain after you've lost 3x appointments worth of billing). So want to take that into account when thinking about RVUs.

You're right though for this setup you should be hitting 300K+ a year pretty easily once you're in your groove after that first year of building up a panel which isn't bad, it's just the call that stands out here which makes this a little less desirable given the other options out there. However, I would say that should be pretty typical for a full outpatient panel in C+A W2 position from what I've seen, so like other people have said nothing really bad about this gig but nothing great either. Agree that if they're making you take call I would negotiate for a week more of vacation/sick days at least and drop the non-compete. I bet they aren't getting a ton of takers with having to take phone calls for a week and round 5x a year.

 

[rjs2131]

Thanks everyone!

Sounds like I'll definitely be looking for more vacation/sick days, dropping the non-compete and asking for longer intake times (75-90 min).

Billing just north of $300/hour is not an unusual or absurd rate. Curious if you have ever tried to hire a lawyer or even a financial advisor with a bachelors degree and some letters after their name (decent ones are all >$300/hour).

I have - but from what I've seen not a lot of these folks are billing >$300/hr for 30-35 hrs/week on a consistent basis.

The point about Medicaid patients is interesting, to me it seems like a double-edged sword. Yes there will be no-shows and thus less revenue, but at the same time with a base guarantee and my preference for work/life balance, if this means a few pts/day don't show and I have more admin time...win-win?

 

[rjs2131]

As a follow-up - is it typical to be hit with a brick wall when first attempting to negotiate? Seems like that's been the norm for a lot of places and can be pretty disheartening (but I guess that's the point). I guess you could walk away from offers until someone eventually decides to negotiate but that gets to be exhausting. Not sure if there is a better way to approach these discussions other than "this is what other places are offering, what can you offer".

 

[Merovinge]

As a follow-up - is it typical to be hit with a brick wall when first attempting to negotiate? Seems like that's been the norm for a lot of places and can be pretty disheartening (but I guess that's the point). I guess you could walk away from offers until someone eventually decides to negotiate but that gets to be exhausting. Not sure if there is a better way to approach these discussions other than "this is what other places are offering, what can you offer".


I have - but from what I've seen not a lot of these folks are billing >$300/hr for 30-35 hrs/week on a consistent basis.

There are many many attorney's who are billing for 30 billable hours in a week on a consistent basis (and plenty at hourly rates that dwarf $300). Many many CPAs who are as well around that range or certainly in the solid $200's/hour that are billing 30+ hours/week. Not comparing those professions to medicine for many reasons but I think you wildly discount the value of a physician if you think $300/hour is an outlandish rate. My friend recently started a PP billing $450/hour (in CAP) and has a full practice within a few months of opening.

Negotiating is going to vary wildly based on 1) the organization 2) the individual you are negotiating with 3) their perceived notion of your ability to negotiate and your desire for the job/alternative options and 4) how in need they are to fill the position. Keep in mind that in some instances the people you are negotiating with have spent hundreds to thousands of hours practicing this, you have likely spent less than a dozen. They literally pray on your weakness/inexperience for a living. There are very few things more empowering for you then actually have alternative offers and being willing to walk away. I am actually in the process of job hunting myself and I tell every place about the other locations in the area (which they know are hiring) because literally every organization is hurting on CAP in the area I am moving to. They reference this on multiple occasions and know that I am going to take the best offer for myself/family. You may find outsourcing this work to a physician contract review organization or JD helpful, although I personally believe it's an important skill to have over the course of your professional life.

 

[rjs2131]

There are many many attorney's who are billing for 30 billable hours in a week on a consistent basis (and plenty at hourly rates that dwarf $300). Many many CPAs who are as well around that range or certainly in the solid $200's/hour that are billing 30+ hours/week. Not comparing those professions to medicine for many reasons but I think you wildly discount the value of a physician if you think $300/hour is an outlandish rate. My friend recently started a PP billing $450/hour (in CAP) and has a full practice within a few months of opening.

Negotiating is going to vary wildly based on 1) the organization 2) the individual you are negotiating with 3) their perceived notion of your ability to negotiate and your desire for the job/alternative options and 4) how in need they are to fill the position. Keep in mind that in some instances the people you are negotiating with have spent hundreds to thousands of hours practicing this, you have likely spent less than a dozen. They literally pray on your weakness/inexperience for a living. There are very few things more empowering for you then actually have alternative offers and being willing to walk away. I am actually in the process of job hunting myself and I tell every place about the other locations in the area (which they know are hiring) because literally every organization is hurting on CAP in the area I am moving to. They reference this on multiple occasions and know that I am going to take the best offer for myself/family. You may find outsourcing this work to a physician contract review organization or JD helpful, although I personally believe it's an important skill to have over the course of your professional life.

Agree with this and want to clarify - I never said $300/hr is an outlandish rate! I am simply comparing offers and have yet to see a hospital or large organization pay a child psychiatrist $3-400/hr on a consistent basis...this would translate to well above 400k/year (with benefits) for an outpatient position of 30-32 hrs/week for 46 weeks per year which I’ve never heard of outside of PP. If you’re seeing positions where this is the norm than maybe I’ve just been looking in all the wrong places.

My lack of experience with negotiating is obvious to most employers but hey, can’t do much about that and I’m trying my best. I’m able to walk away and take a different position and that has been expressed...but maybe that isn’t enough to get places to budge. I doubt any of the places I’m considering have a swarm of CAPs they’re considering (I’d guess 1 or 2 others at the most) but I’d have no way of knowing.

Seems like standing my ground and playing the waiting game are the only ways to move forward, but open to any other thoughts/advice.

 

[Merovinge]

Agree with this and want to clarify - I never said $300/hr is an outlandish rate! I am simply comparing offers and have yet to see a hospital or large organization pay a child psychiatrist $3-400/hr on a consistent basis...this would translate to well above 400k/year (with benefits) for an outpatient position of 30-32 hrs/week for 46 weeks per year which I’ve never heard of outside of PP. If you’re seeing positions where this is the norm than maybe I’ve just been looking in all the wrong places.

My lack of experience with negotiating is obvious to most employers but hey, can’t do much about that and I’m trying my best. I’m able to walk away and take a different position and that has been expressed...but maybe that isn’t enough to get places to budge. I doubt any of the places I’m considering have a swarm of CAPs they’re considering (I’d guess 1 or 2 others at the most) but I’d have no way of knowing.

Seems like standing my ground and playing the waiting game are the only ways to move forward, but open to any other thoughts/advice.

Of course a large organization is not going to pay you 400k/year because they either use your earnings to fuel their bureaucracy and pay their administrators 7 figures or in other cases are taking on insurance that actually causes them to lose money on you. The only employed jobs you will find that might sniff those numbers would be the absolute most undesirable of locations; I have received 1 spam email offer in the last 5 years advertising the mythical 400k psych employed job for point of reference.

Some places will not budge with offers and I think that's an important consideration when understanding what they will be like to work with. In some cases where the terms are actually reasonable, this makes sense, but when the terms are very anti-physician (horrible PTO, non-compete, etc), this gives you an idea what it will be like working for said organization. Many places can get by only taking docs who do not know their worth and are just excited to be employed with a relatively large monthly take home. You might think the internet age is changing this (and it is slightly), but given our training where we are repeatedly told to be door mats, put patients first, and not consider ourselves, combined with large debt levels that drive people into denial over finances, we are the last large whale to be taken advantage of by the financial sector and MBAs running businesses. Business folks literally make Moby Dick jokes when talking about dealing with physicians.

 

[Sushirolls]

As a follow-up - is it typical to be hit with a brick wall when first attempting to negotiate? Seems like that's been the norm for a lot of places and can be pretty disheartening (but I guess that's the point). I guess you could walk away from offers until someone eventually decides to negotiate but that gets to be exhausting. Not sure if there is a better way to approach these discussions other than "this is what other places are offering, what can you offer".

Remove yourself from the conversation, and request your attorney take over.

Reply something like this:
Thank you for getting this contract to me so quickly. It has a lot of good points. I am going to have my attorney look this over, do you have a counsel or particular person of contact my attorney should be in touch with for any needed adjustments?

Now you talk with your attorney about getting things changed, they then communicate to make it happen.

 

[rjs2131]

Remove yourself from the conversation, and request your attorney take over.

Reply something like this:
Thank you for getting this contract to me so quickly. It has a lot of good points. I am going to have my attorney look this over, do you have a counsel or particular person of contact my attorney should be in touch with for any needed adjustments?

Now you talk with your attorney about getting things changed, they then communicate to make it happen.

This makes a lot of sense - some of the attorneys I've reached out to seem to function in more of a "we'll review your contract and send you edits" capacity vs actually going to bat for me. Is this typical? I would hope that if I'm paying them they'd take charge of the communication with the employers' counsel.

 

[Sushirolls]

This makes a lot of sense - some of the attorneys I've reached out to seem to function in more of a "we'll review your contract and send you edits" capacity vs actually going to bat for me. Is this typical? I would hope that if I'm paying them they'd take charge of the communication with the employers' counsel.

Sadly I've acquired more experience with attorneys over the years. Try to find a generic general attorney who becomes your go to. A PCP for legal issues. Shop around for price too. Not all are $300+. Some will do the negotiation side of things, naturally in discussion with you.

Don't be afraid to try a few out, to find the one that is willing to drop their legal guard down a bit to be straightforward with you to say, "this will be a waste of your time and not worth the effort." Oddly, lawyers actually get saddled with a lot of mental health supportive therapy and listening to people's "I'm a victim" stories and then nicely saying yeah, sort of, but no I don't have the answers you seek for your perceived wrong doings.

 

[Stagg737]

Agree with above that the vacation time is also terrible. 4 weeks total for vacation, sick, and CME is a recipe for burnout. My is 3 weeks vacation, 2 weeks sick, and 1 week CME. Pretty sure attending setup is very similar except they can sell back unused days or donate them to others.

- Base - 265K guarantee, once wRVU threshold of 4000 wRVUs exceeded, pays ~$64/wRVU

Something else no one has asked. Is this threshold for RVUs billed or collected? I've got a couple of very nice looking offers from recruiters which turn out to be much worse once I found out the productivity was based on collected and not billed.

 

[AD04]

As a follow-up - is it typical to be hit with a brick wall when first attempting to negotiate? Seems like that's been the norm for a lot of places and can be pretty disheartening (but I guess that's the point). I guess you could walk away from offers until someone eventually decides to negotiate but that gets to be exhausting. Not sure if there is a better way to approach these discussions other than "this is what other places are offering, what can you offer".

It is uncommon to be hit with a brick wall as most places will make some concessions. If a place will make absolutely no concessions, don't be surprised if the employer doesn't listen to your suggestions if you're working for them. If am employer change the terms of the contract without your knowledge in the middle of negotiations, get out and cut your loss. This reflects poorly on the employer and the employer either is incompetent or dishonest.

Most places are willing to make concessions that don't affect the spirit of the contract. They are unlikely going to change the main components of the contract. That is why you need to ask all questions during the phone call about whatever you care about prior to going on the site visit. I weed out 20 - 30 places before I go on one site visit. Pay special attention how they treat you during negotiations.

One of my friends was working for an addiction facility. I wanted to work there on the weekends. However, the employer / medical director just wouldn't budge on the indemnification clause but couldn't tell me why. As a result, negotiations broke down and I didn't work there. After a few months, the medical director was canned. After a few more months, my friend moved on from that facility as he couldn't deal with the administration.

Be professional but don't be a push-over. Test them. Action speaks louder than words. And always be willing to walk away.

P.S. I would recommend you negotiate for yourself instead of getting a lawyer to negotiate on your behalf. Have the lawyer review the contract and make suggestions on what to improve. But you should look at the contract and see what you would like improved as well. Then you should negotiate directly with the employer. You'll learn more by doing and learning about negotiating will be invaluable.

 

[rjs2131]

Agree with above that the vacation time is also terrible. 4 weeks total for vacation, sick, and CME is a recipe for burnout. My is 3 weeks vacation, 2 weeks sick, and 1 week CME. Pretty sure attending setup is very similar except they can sell back unused days or donate them to others.



Something else no one has asked. Is this threshold for RVUs billed or collected? I've got a couple of very nice looking offers from recruiters which turn out to be much worse once I found out the productivity was based on collected and not billed.

Great thought - I'll definitely clarify this piece. Didn't even think to ask about RVUs billed vs collected outside of the PP's I've been considering.

It is uncommon to be hit with a brick wall as most places will make some concessions. If a place will make absolutely no concessions, don't be surprised if the employer doesn't listen to your suggestions if you're working for them. If am employer change the terms of the contract without your knowledge in the middle of negotiations, get out and cut your loss. This reflects poorly on the employer and the employer either is incompetent or dishonest.

Most places are willing to make concessions that don't affect the spirit of the contract. They are unlikely going to change the main components of the contract. That is why you need to ask all questions during the phone call about whatever you care about prior to going on the site visit. I weed out 20 - 30 places before I go on one site visit. Pay special attention how they treat you during negotiations.

One of my friends was working for an addiction facility. I wanted to work there on the weekends. However, the employer / medical director just wouldn't budge on the indemnification clause but couldn't tell me why. As a result, negotiations broke down and I didn't work there. After a few months, the medical director was canned. After a few more months, my friend moved on from that facility as he couldn't deal with the administration.

Be professional but don't be a push-over. Test them. Action speaks louder than words. And always be willing to walk away.

P.S. I would recommend you negotiate for yourself instead of getting a lawyer to negotiate on your behalf. Have the lawyer review the contract and make suggestions on what to improve. But you should look at the contract and see what you would like improved as well. Then you should negotiate directly with the employer. You'll learn more by doing and learning about negotiating will be invaluable.

Appreciate the feedback - I was surprised about many of these positions politely saying they weren't willing to budge, but it made me wonder how much of this is related to me being a new grad and the employer's experience that most new grads just take what is offered to them. I also wonder if this is the initial "go-to" move for these employers and once you make it clear you won't move forward, that is when the actual negotiating begins.

I've certainly tried negotiating for myself and thus far, when I bring offer A to employer B, employer B's response is to try and justify why they are still the better employer/job without making any concessions. Either that or employer B simply states, "we can't match that" and doesn't even try. It's been frustrating to say the least.

 

[Merovinge]

I've certainly tried negotiating for myself and thus far, when I bring offer A to employer B, employer B's response is to try and justify why they are still the better employer/job without making any concessions. Either that or employer B simply states, "we can't match that" and doesn't even try. It's been frustrating to say the least.

If you are not going to be talking to a professional (MD contract review firm like Contract diagnostics or the like, or a contract lawyer), you definitely need to be talking to colleagues you know who have been through the process. You have significant disadvantages, including your age/freshness and information asymmetry they are trying to exploit (i.e. they know how much they are paying their docs with what benefits, you do not) so I would approach it like going into a battle where I know my opponent has the upper hand and where I need every possible support/advantage to make up for this.

 

[hebel]

Great thought - I'll definitely clarify this piece. Didn't even think to ask about RVUs billed vs collected outside of the PP's I've been considering.


Appreciate the feedback - I was surprised about many of these positions politely saying they weren't willing to budge, but it made me wonder how much of this is related to me being a new grad and the employer's experience that most new grads just take what is offered to them. I also wonder if this is the initial "go-to" move for these employers and once you make it clear you won't move forward, that is when the actual negotiating begins.

I've certainly tried negotiating for myself and thus far, when I bring offer A to employer B, employer B's response is to try and justify why they are still the better employer/job without making any concessions. Either that or employer B simply states, "we can't match that" and doesn't even try. It's been frustrating to say the least.

In addition to using a lawyer, I have another option you could also try that is strictly based on my experience, so I don't know if this is good advice for everyone.

If you hit a wall in negotiating, don't commit to walking away for good. Instead, let them know you appreciate their time and politely say that you are going to look at other options for the time being and will reconnect with them at a later time. This of course is more effective if you start your job search early, so have the luxury of time.

I did this, and this caused the current job I'm at to suddenly increase my salary offer by about 40k. It's kind of like a walk-away, without the downside of actually walking away from an offer for good.

 

[Stagg737]

In addition to using a lawyer, I have another option you could also try that is strictly based on my experience, so I don't know if this is good advice for everyone.

If you hit a wall in negotiating, don't commit to walking away for good. Instead, let them know you appreciate their time and politely say that you are going to look at other options for the time being and will reconnect with them at a later time. This of course is more effective if you start your job search early, so have the luxury of time.

I did this, and this caused the current job I'm at to suddenly increase my salary offer by about 40k. It's kind of like a walk-away, without the downside of actually walking away from an offer for good.

I think this is great advice if the job isn't malignant. It shows one is interested but that the offer doesn't meet minimum expectations while leaving the door open for the employer. If they really want someone, they'll make a new offer or reach out again. If they don't budge or say no thanks, either your requests are unrealistic for them or they're probably not a very god place to work.

If someone does this though and goes back to that employer, they need to have some better offers to show or leverage otherwise the employer isn't going to budge.

 

[rjs2131]

In addition to using a lawyer, I have another option you could also try that is strictly based on my experience, so I don't know if this is good advice for everyone.

If you hit a wall in negotiating, don't commit to walking away for good. Instead, let them know you appreciate their time and politely say that you are going to look at other options for the time being and will reconnect with them at a later time. This of course is more effective if you start your job search early, so have the luxury of time.

I did this, and this caused the current job I'm at to suddenly increase my salary offer by about 40k. It's kind of like a walk-away, without the downside of actually walking away from an offer for good.

This makes a lot of sense and I've done this for one position - we'll see if they actually come back with anything. Hopefully if I'm able to do this + present alternative job offers, at least a few places will be willing to negotiate.

 

[rjs2131]

Update - some increase in $/wRVU ($70) but not much movement with more time off/more flexibility during the week (i.e. 30 clinical hours vs 34 clinical hours). Seems like the latter would be an easier thing to change as long as I'm hitting my wRVU target, which once full I think would be fine (90-100 wRVU's/week would get me there, independent of call).

Any suggestions on how to approach this? I have a BATNA and have made it clear that I value work/life balance > $$$ (within reason). Not sure if there are any other cards to play at this point, but would love for this position to work out.

 

[Merovinge]

Update - some increase in $/wRVU ($70) but not much movement with more time off/more flexibility during the week (i.e. 30 clinical hours vs 34 clinical hours). Seems like the latter would be an easier thing to change as long as I'm hitting my wRVU target, which once full I think would be fine (90-100 wRVU's/week would get me there, independent of call).

Any suggestions on how to approach this? I have a BATNA and have made it clear that I value work/life balance > $$$ (within reason). Not sure if there are any other cards to play at this point, but would love for this position to work out.

Job is going to end up paying pretty well if your no show rate is low to average and you bill correctly/are allowed to bill with psychotherapy add on codes (even if they don't get paid but still generate wRVU). It's a lot of clinical hours with short intakes and very little time off (and actually every two months youll work 12 days straight from what I understand), so if you are okay being on the "grind" for CAP then you could do worse (of course your hours will be a joke compared to neurosurgery or an investment banker). I think a non-compete is a total no-starter if I'm staying in the area, since it's likely you will want out after a few years.

 

[nrmp]

I wouldn't take this job.

 

[rjs2131]

I wouldn't take this job.

What would you need to see to change your mind? Anything in particular that sticks out?

I think outside of joining a PP (which is my primary alternative), this is actually the best $$$ I'm seeing for larger organizations/hospital systems in my area. Definitely more work than PP, but income potential is also higher.

 

[deleted314957]

Yeah - every 9-10 weeks or so. My understanding is phone coverage during the week for any after hours floor issues and then weekend rounding.
Insurance is a mix of medicaid and private. Seems like support staff are solid from what I can gather...agree about the non-compete!

Non-compete would undoubtedly found non enforceable in court.

 

[Merovinge]

Non-compete would undoubtedly found non enforceable in court.

You do not want to be in the lawsuit anyway, my current system has multiple lawsuits open at this very moment with ex-doctors from the system. Lawsuits are a huge headache even if they are not for malpractice.

 

[rjs2131]

Thanks all!

I'm also noticing that most employers aren't using the updated wRVU conversion for 2021 below:

RVU21A | CMS

www.cms.gov

This means ~1 less wRVU for 90792's, ~0.4 less wRVU's for 99214's (among other things)...are employers legally required to updated their wRVU schedules? I guess they could just increase the wRVU threshold for a position to make up for it but the new conversions would result in a significant increase in wRVU's/year. Not sure if it's worth my time to explore this further with employers but would imagine they're being reimbursed a bit more with these changes.

 

[Sushirolls]

Non-compete would undoubtedly found non enforceable in court.

Very state dependent.

 

[Sushirolls]

Thanks all!

I'm also noticing that most employers aren't using the updated wRVU conversion for 2021 below:

RVU21A | CMS

www.cms.gov

This means ~1 less wRVU for 90792's, ~0.4 less wRVU's for 99214's (among other things)...are employers legally required to updated their wRVU schedules? I guess they could just increase the wRVU threshold for a position to make up for it but the new conversions would result in a significant increase in wRVU's/year. Not sure if it's worth my time to explore this further with employers but would imagine they're being reimbursed a bit more with these changes.

They aren't obligated to. And they will squirm away from paying you more, because, why? That's what Big Box shops do. They point you to the coal mine. Start shoveling. They don't care about you, fairness, etc.

 

[AD04]

You do not want to be in the lawsuit anyway, my current system has multiple lawsuits open at this very moment with ex-doctors from the system. Lawsuits are a huge headache even if they are not for malpractice.

Why are there multiple lawsuits?

If I remember correctly, your current system also enact policy changes for physicians with little notice. Why is your place so malignant?

 

[AD04]

Thanks all!

I'm also noticing that most employers aren't using the updated wRVU conversion for 2021 below:

RVU21A | CMS

www.cms.gov

This means ~1 less wRVU for 90792's, ~0.4 less wRVU's for 99214's (among other things)...are employers legally required to updated their wRVU schedules? I guess they could just increase the wRVU threshold for a position to make up for it but the new conversions would result in a significant increase in wRVU's/year. Not sure if it's worth my time to explore this further with employers but would imagine they're being reimbursed a bit more with these changes.

My job is using 2021 wRVU rates.

You should look into it and negotiate as you didn't sign the contract yet. If administration isn't trustworthy, walk away.

 

[Merovinge]

Why are there multiple lawsuits?

If I remember correctly, your current system also enact policy changes for physicians with little notice. Why is your place so malignant?

Because they can be? It's the only real gig in town and they have some additional advantages with being a major visa supplier. I'm looking to get out as soon as my contract is up and will either be doing PP or working for a psychiatrist owned PhP/IOP, but I assure you there are many other hospital systems out there just as malignant as mine. In fact, this very thread is about a system that judging from their non-compete and time off may be just as much so.

 

[AD04]

Because they can be? It's the only real gig in town and they have some additional advantages with being a major visa supplier. I'm looking to get out as soon as my contract is up and will either be doing PP or working for a psychiatrist owned PhP/IOP, but I assure you there are many other hospital systems out there just as malignant as mine. In fact, this very thread is about a system that judging from their non-compete and time off may be just as much so.

Good sentence at the end. You can tell a lot about the other side by their actions (e.g. conduct during the interview, clauses in the contract, conduct during negotiation process). This is why physicians should negotiate the contract themselves instead of relying on a 3rd party to do so.

And regarding lawsuits, don't sign a contract you cannot keep. If you expect the other side to follow what's in the contract, you too should follow what's in the contract. If I leave, I follow protocol exactly as per the contract. Leaving could sour the relationship and any deviation from the contract could be used against you. So one of the most important things to negotiate is termination.

If your place is so bad and still physicians are signing on with them, then they don't have an incentive to change.