Tips - Setting up Anesthesia Group?

[NothingLastsForever]

Hi y'all,

I've been approached by a close friend who is interested in gathering a group of CNRAs and anesthesiologists to service a handful (not huge amount!) of ASCs in California. We would not provide trauma or overnight coverage. We would not bill out-of-network. The idea would be for us as management group owners to collect a stipend/daily minimum and also do our own billing. Each person would be responsible for paying for their malpractice coverage and will be paid via a 1099. We want to make sure that each person is paid fairly and does not go to a dump that doesn't have oxygen. I am quite leery of surgeons and owners of wanting to pay terrible stipends, having six non-paid hours in between cases, and having a terrible payer mix. I have not formally ran a pro forma but I sense if the center has a terrible payer mix or is very slow then the higher the stipend would have to be. Back of the napkin estimates would put us at taking $75-$80 per hour from what the center pays us and what we give to each person in the group.

For anyone who is set up a group or has been part of a small group:
1. What pitfalls am I missing? What landmines should I look out for?
2. How hard is anesthesia billing exactly? I'm an anesthesiologist but have not billed for my own cases.
3. Is this worth the headache?
4. Is there anything we can do to limit our risks (ie getting stiffed on payments, being dragged into a lawsuit etc)?

TIA

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[UscGhost]

Few challenges:
Margins are pretty thin in California. And you need to have big enough margins to make it worth taking the risk. Is all the risk and headache worth 5-10%? Anything more than that and the workers will think you're greedy

Those that you manage will always think that you are taking a big cut and they will undervalue your management responsibilities

Labor shortage right now, so people want more for less

Creating a rotating schedule, vacations, etc is challenging and ripe for conflicts

Really need the right mix of core people who won't be nitpicking every lineup they get, and a few expendable folks who might leave of they don't get the best lineups

Goodluck!!

 

[centdoc]

As for billing, go ahead and factor anywhere from 2-10% for their fee. And remember, they will not be able to get every dollar owed even if you’re in-network with the payer.

 

[AKMD_1984]

Hi y'all,

I've been approached by a close friend who is interested in gathering a group of CNRAs and anesthesiologists to service a handful (not huge amount!) of ASCs in California. We would not provide trauma or overnight coverage. We would not bill out-of-network. The idea would be for us as management group owners to collect a stipend/daily minimum and also do our own billing. Each person would be responsible for paying for their malpractice coverage and will be paid via a 1099. We want to make sure that each person is paid fairly and does not go to a dump that doesn't have oxygen. I am quite leery of surgeons and owners of wanting to pay terrible stipends, having six non-paid hours in between cases, and having a terrible payer mix. I have not formally ran a pro forma but I sense if the center has a terrible payer mix or is very slow then the higher the stipend would have to be. Back of the napkin estimates would put us at taking $75-$80 per hour from what the center pays us and what we give to each person in the group.

For anyone who is set up a group or has been part of a small group:
1. What pitfalls am I missing? What landmines should I look out for?
2. How hard is anesthesia billing exactly? I'm an anesthesiologist but have not billed for my own cases.
3. Is this worth the headache?
4. Is there anything we can do to limit our risks (ie getting stiffed on payments, being dragged into a lawsuit etc)?

TIA

Seems like a lot of risk

Easy way to do this is to look at last two years collections, volume, and type of cases plus schedule.

Hand over the billing to them.

And just charge a reasonable rate for labor for all of your partners.

When you hand over the billing to them, they’ll feel good. There’s no point in asking for subsidy plus billing. Give it to them and you tahr your guaranteed pay and whatever the difference is between collections and your income, is your built in stipend.

This way you never discuss stipend per se.

As for yourself, ask for a 50-75k stipend on top of the exact pay that your colleagues are getting for:

1. Scheduling
2. Coordinating
3. Policy making
4. Emergency/ backup call


Keep the workload equal by weekly production and time commitment and reward those who are productive and do more.

Make sure to get overtime or additional pay per day after 5 pm so you’re not affected by surgeon behavior and lack of efficiency.

It will work.

Billing won’t make you whole - it’s too risky.

 

[aneftp]

Avoid 100% of billing responsibilities these day

You need at least a 250k subsidy PER ROOM per year in an ASC and even than the margins are slim

If ASC runs 4 rooms. You need 1 million subsidy plus keep all the billing

There is a reason there is a lot of turnover of anesthesia companies who run ASC

ASC ortho center I know gets subsidy of $250k per room and it’s still not enough money paying anesthesia doc 500k and 2.5 crnas 300k each (650k) plus vacation coverage pay

That’s 750k in subsidy plus billing.

 

[teacher2md]

Avoid 100% of billing responsibilities these day

You need at least a 250k subsidy PER ROOM per year in an ASC and even than the margins are slim

If ASC runs 4 rooms. You need 1 million subsidy plus keep all the billing

There is a reason there is a lot of turnover of anesthesia companies who run ASC

ASC ortho center I know gets subsidy of $250k per room and it’s still not enough money paying anesthesia doc 500k and 2.5 crnas 300k each (650k) plus vacation coverage pay

That’s 750k in subsidy plus billing.

Do you have any data or articles to back up these numbers re: subsidy per ASC room?

Is $250k per ASC room really the standard nationwide?

 

[sevoflurane]

Do you have any data or articles to back up these numbers re: subsidy per ASC room?

Is $250k per ASC room really the standard nationwide?

I am not sure, but ASC's are dying if you don't have good payer mix or a revenue guarantee.
Times are changing. We recently pulled out of an RFP because business is so strong, we just didn't need an ASC to distract us.
We are plenty busy at the big house. ASC's that are not efficient with scheduling are a net loss a lot of times.

 

[UscGhost]

Avoid 100% of billing responsibilities these day

You need at least a 250k subsidy PER ROOM per year in an ASC and even than the margins are slim

If ASC runs 4 rooms. You need 1 million subsidy plus keep all the billing

There is a reason there is a lot of turnover of anesthesia companies who run ASC

ASC ortho center I know gets subsidy of $250k per room and it’s still not enough money paying anesthesia doc 500k and 2.5 crnas 300k each (650k) plus vacation coverage pay

That’s 750k in subsidy plus billing.

That seems extremely high. I doubt most ASCs even profit 250k per year.

Must be in very busy, excellent ppo, highly efficient ASCs.

ASC anesthesiologist shouldn't expect to make as much as a hospital based one. ASCs have fewer hours, no call/weekends and healthier patients.

Probably 70-75% of the income of a hospital anes

 

[aneftp]

That seems extremely high. I doubt most ASCs even profit 250k per year.

Must be in very busy, excellent ppo, highly efficient ASCs.

ASC anesthesiologist shouldn't expect to make as much as a hospital based one. ASCs have fewer hours, no call/weekends and healthier patients.

Probably 70-75% of the income of a hospital anes

We are truly in the wild Wild West.

The ASC is paying those numbers for subsidies. Very busy ortho center. 10-15 blocks a day for the doc. And they still can’t get anesthesia to cover. That’s how wild it is

I don’t know about your area maybe ASC runs a true 7-3p


But most ASC I been at run 6am-6pm consistently. Those are long days.

These are just random texts I got from my docs friends this week

“I am there tomorrow. 44 patients. 12 Nerve blocks, etc, 12 peds ent”

“About 6 or 7 surgeons worked that day. 3 surgeons doing pediatric cases, youngest I did was 17 months. U/S IV placements, nerve blocks (tap, rectus sheath, pec blocks, etc). Finished at 9pm! “ that was downtown

Than he went to another surgery center down the street from me in the suburbs today

“ Actually, I thought today would be an early day. But this guy is hours behind. Looking like another 9pm or 10pm night at this surg center. I guess if one likes a lot of hours it is a good place. But if you want short easy days, this is not the place to be.”

“Yeah. I am not too happy today.”

Here is another quote from another doc today
“I am exhausted working today, clocked out at 1815, 12 hours of work” 12 blocks today. 23 patients

Just 3 random surgery centers in Florida.

And I’m chillin at the regular w2 hospital. Out at 1pm. Out by 3pm tomorrow. While not all surgery centers are long. Many are a solid 10 plus hours. Those are long days and busy days.

Bottom line is it’s easier to do hospital work than surgery center work. That’s a reason surgery centers can’t hire full time docs anymore

 

[UscGhost]

We are truly in the wild Wild West.

The ASC is paying those numbers for subsidies. Very busy ortho center. 10-15 blocks a day for the doc. And they still can’t get anesthesia to cover. That’s how wild it is

I don’t know about your area maybe ASC runs a true 7-3p


But most ASC I been at run 6am-6pm consistently. Those are long days.

These are just random texts I got from my docs friends this week

“I am there tomorrow. 44 patients. 12 Nerve blocks, etc, 12 peds ent”

“About 6 or 7 surgeons worked that day. 3 surgeons doing pediatric cases, youngest I did was 17 months. U/S IV placements, nerve blocks (tap, rectus sheath, pec blocks, etc). Finished at 9pm! “ that was downtown

Than he went to another surgery center down the street from me in the suburbs today

“ Actually, I thought today would be an early day. But this guy is hours behind. Looking like another 9pm or 10pm night at this surg center. I guess if one likes a lot of hours it is a good place. But if you want short easy days, this is not the place to be.”

“Yeah. I am not too happy today.”

Here is another quote from another doc today
“I am exhausted working today, clocked out at 1815, 12 hours of work” 12 blocks today. 23 patients

Just 3 random surgery centers in Florida.

And I’m chillin at the regular w2 hospital. Out at 1pm. Out by 3pm tomorrow. While not all surgery centers are long. Many are a solid 10 plus hours. Those are long days and busy days.

Bottom line is it’s easier to do hospital work than surgery center work. That’s a reason surgery centers can’t hire full time docs anymore

Yikes.

Yea, most ASCs in so cal aren't that busy.

That sounds like quite the exhausting day

 

[AKMD_1984]

We are truly in the wild Wild West.

The ASC is paying those numbers for subsidies. Very busy ortho center. 10-15 blocks a day for the doc. And they still can’t get anesthesia to cover. That’s how wild it is

I don’t know about your area maybe ASC runs a true 7-3p


But most ASC I been at run 6am-6pm consistently. Those are long days.

These are just random texts I got from my docs friends this week

“I am there tomorrow. 44 patients. 12 Nerve blocks, etc, 12 peds ent”

“About 6 or 7 surgeons worked that day. 3 surgeons doing pediatric cases, youngest I did was 17 months. U/S IV placements, nerve blocks (tap, rectus sheath, pec blocks, etc). Finished at 9pm! “ that was downtown

Than he went to another surgery center down the street from me in the suburbs today

“ Actually, I thought today would be an early day. But this guy is hours behind. Looking like another 9pm or 10pm night at this surg center. I guess if one likes a lot of hours it is a good place. But if you want short easy days, this is not the place to be.”

“Yeah. I am not too happy today.”

Here is another quote from another doc today
“I am exhausted working today, clocked out at 1815, 12 hours of work” 12 blocks today. 23 patients

Just 3 random surgery centers in Florida.

And I’m chillin at the regular w2 hospital. Out at 1pm. Out by 3pm tomorrow. While not all surgery centers are long. Many are a solid 10 plus hours. Those are long days and busy days.

Bottom line is it’s easier to do hospital work than surgery center work. That’s a reason surgery centers can’t hire full time docs anymore

This is true.
It’s because surgeon owners consider their ASCs as mini hospitals but they get to run the show.

Very prevalent in Texas.

They want you to make money for them at basically cater to them and their inefficiencies. Also loading up as many cases as possible helps them, not you as the anesthesia company or the anesthesiologist. That’s why I said make sure you ask for a time based compensation after 5 pm so you’re not stuck there everyday 6-7 pm.

Also no one should do 100% asc work because over time you’ll lose your skillls in managing high acuity patients and doing lines etc.

Also if you’re the medical director for an asc, you cannot step out easily if there’s a family emergency, and have easy cross coverage during day time like a hospital.

 

[caligas]

Get revenue guarantees, use negotiation consultant.

But honestly why take all the risk and stress and unpaid effort when you can make $400/hr doing locums?

 

[NicholasPavona]

My tip? Stay employed or do locums.

 

[nimbus]

We are truly in the wild Wild West.

The ASC is paying those numbers for subsidies. Very busy ortho center. 10-15 blocks a day for the doc. And they still can’t get anesthesia to cover. That’s how wild it is

I don’t know about your area maybe ASC runs a true 7-3p


But most ASC I been at run 6am-6pm consistently. Those are long days.

These are just random texts I got from my docs friends this week

“I am there tomorrow. 44 patients. 12 Nerve blocks, etc, 12 peds ent”

“About 6 or 7 surgeons worked that day. 3 surgeons doing pediatric cases, youngest I did was 17 months. U/S IV placements, nerve blocks (tap, rectus sheath, pec blocks, etc). Finished at 9pm! “ that was downtown

Than he went to another surgery center down the street from me in the suburbs today

“ Actually, I thought today would be an early day. But this guy is hours behind. Looking like another 9pm or 10pm night at this surg center. I guess if one likes a lot of hours it is a good place. But if you want short easy days, this is not the place to be.”

“Yeah. I am not too happy today.”

Here is another quote from another doc today
“I am exhausted working today, clocked out at 1815, 12 hours of work” 12 blocks today. 23 patients

Just 3 random surgery centers in Florida.

And I’m chillin at the regular w2 hospital. Out at 1pm. Out by 3pm tomorrow. While not all surgery centers are long. Many are a solid 10 plus hours. Those are long days and busy days.

Bottom line is it’s easier to do hospital work than surgery center work. That’s a reason surgery centers can’t hire full time docs anymore

Nurses at ASCs I’ve experienced will not stay that late. Hospitals pay more than ASCs for RNs. The reason nurses in our area work at ASCs is because they offer no call and out early. We recently cancelled a case at one ASC because the room was running late and no cases start after 3pm.

 

[aneftp]

Nurses at ASCs I’ve experienced will not stay that late. Hospitals pay more than ASCs for RNs. The reason nurses in our area work at ASCs is because they offer no call and out early. We recently cancelled a case at one ASC because the room was running late and no cases start after 3pm.

It may be a regional (location trend) but the nurses at ASC I got to don’t work 5 days. They work 3-4 days a week. Thus can handle the 10-12 hr days.

Yes. Many like to work 630-3p. But they are 0.8 fte. The 1.0 work 3-4
Days a week. So they have staff to cover longer days.

 

[jwk]

Nurses at ASCs I’ve experienced will not stay that late. Hospitals pay more than ASCs for RNs. The reason nurses in our area work at ASCs is because they offer no call and out early. We recently cancelled a case at one ASC because the room was running late and no cases start after 3pm.

We get the same pushback from our nurses and I don't blame them. They left the hospital to avoid late unpredictable days, call, nights, and weekends.

 

[CleanUp]

How do the large management companies make it work? Cover lots of places? Only cherry pick good insurers? Low ball the physicians?

 

[aneftp]

How do the large management companies make it work? Cover lots of places? Only cherry pick good insurers? Low ball the physicians?

1. Immediate 6% cost savings with billing (because they have they own billing team that can handle multiple centers at the same time)
2. Higher level with negotiations with private insurers. As a private group we were lucky to get $70-80 a unit from insurers. While a large entity like usap could command 30% more by sheer size (just looked at Colorado lawsuit against usap)

those are the two main things.

But as mention above. Due to inflation. Rising crna costs. Surgery center inefficiencies on their own. Lots of factors make surgery centers unattractive to take over the billing.

It’s a difficult conversation with the surgery center owners (often physicians owners). And AMC have more insight to ask for subsidies. Which were almost unheard of even as 2 years ago. No surgery centers have succomb to giving out subsidies or guarantee hours to anesthesia.

 

[dmk5n]

If you have enough people, might be worth pooling your bodies for a health insurance rate, etc...But may not be worth the trouble or time.

 

[nimbus]

No surgery centers have succomb to giving out subsidies or guarantee hours to anesthesia.

They have in our region.

 

[DesiredMemberName?]

They have in our region.

Same here. Surgery centers are competing with each other for our services.