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[Yo GabbaPentin]

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I have recently been offered a role supervising two CRNAs at a surgery center. This is one day a week for a surgeon who brings their own CRNAs. The surgeon does not want to be the supervising physician, so it has been offered to me. 90% + of all cases are regional + IV sedation/MAC. I will be getting cases started early and then doing my own cases (pain management).

The CRNAs are part of a group and will bill for the services. This is just the way it has to be, as this is the group that the surgeon requires.

So my question is, how much to I charge this CRNA group for my services? PM's would also be welcome.

And leave politics out of it. I helped to make sure that two anesthesiologists got the contract for the other 4 days a week.

 

[imfrankie]

Why not simplify it and make it $200/hr from the time first patient gets to preop holding until last patient leaves the PACU, with a minimum of 6 hours.

 

[lakerjock]

You can't supervise and be doing pain cases yourself.

 

[Yo GabbaPentin]

It needs to be a flat fee.

And yes, it can be done.

 

[IlDestriero]

$1925/day
Plus any additional malpractice insurance costs.

 

[B-Bone]

Is this medical direction or medical supervision? If med direction, you definitely cannot be doing your own cases or procedures concurrently while supervising (or at least CMS won't pay you to do this). I'm not sure about medical supervision. I know you don't have to meet the strict requirements for direction (present at start/finish/critical portions, monitored at frequent intervals, immediately available at all times, pre/post-op evaluation), but i'm not sure what is exactly required.

 

[Guillemot]

I think you should do it for free. Being a doctor isnt about making money. Im premed at johns hopkins by the way if it matters.

 

[Yo GabbaPentin]

Supervision. Again, I am not billing for this. I am the supervising physician as the surgeon does not want to be responsible for anything anesthesia related. Right now they are offering $400.

 

[imfrankie]

Supervision. Again, I am not billing for this. I am the supervising physician as the surgeon does not want to be responsible for anything anesthesia related. Right now they are offering $400.

Tell them four thousand is too much. You'll do it for half that because you like 'em.

 

[Ronin786]

I think you should do it for free. Being a doctor isnt about making money. Im premed at johns hopkins by the way if it matters.

 

[Yo GabbaPentin]

I know nothing about anesthesia billing. How much would a couple of CRNAs expect to bill for 10-15 quick ortho cases on mostly ASA 2 patients? This surgeon has a high volume of very good payer mix. 0% medicare.

 

[IlDestriero]

They'll probably bill ~$10k and get 5.
$400 for being the malpractice fall guy is an insult. I wouldn't do it at all if I was not going to be available to help in an emergency.

 

[urge]

90% + of all cases are regional + IV sedation/MAC.

Who is doing the blocks? Or do you mean local?

 

[sevoflurane]

I know nothing about anesthesia billing. How much would a couple of CRNAs expect to bill for 10-15 quick ortho cases on mostly ASA 2 patients? This surgeon has a high volume of very good payer mix. 0% medicare.

He's lowballing you big time. 0% medicare is about as good as you can get it. Quick cases are also good. Is this an ASC? Is he part owner? Will YOU be part owner?

7 cases x 10 (start up and minutes) units per case x $50 (which you will get and then some) = $3500 per MD provider- rough estimate. I'm not sure how it works with CRNA's, but it might be close to what ILD said. I think this is lowballing it as some payer mixes @ profitable ASC's are much better than $50/u.

5-8K per day + facility fees is more like it. What is your cut? 1-2K easy. $400 is a joke.

 

[urge]

I imagine you will need extra malpractice insurance for this. I would find out how much per day your premium would cost you then multiply that by 10 or 15.

I doubt your premium would be $40/day for this set up.

 

[urge]

So, I read a little about supervision billing. From what I gather, if you were to make things legal and bill along with the CRNAs the CRNAs would get 50% of the normal anesthesia money, and you would get 3 units per case (4 units if present for induction).

Lets say these are average 8 units/case times 10 cases at $50/unit = $4000 divided by 2 for the CRNAs and 1500 for you if you never participate in inductions.

Looks like they want to keep 100% of the anesthesia bill and have you as a mercenary malpractice guy. Seems to me like you should get some of the pie.

So probably you want $2000 at least.

 

[Yo GabbaPentin]

Guess I should have been more detailed.

I will be doing some of the blocks but the CRNAs will be doing most of them under ultrasound. They have apparently been doing them for years at another surg. center in an opt out state and had no problems. And here is the sad part. This is an ASC which I have some ownership in. The anesthesia group (3 guys) that I helped get hired has NO REGIONAL EXPERIENCE! I would have to go over an do all of the blocks for them and I have absolutely no time for that. So in this case, the skills which the CRNAs have and anesthesiologists lack, was the reason we brought them in! Important lesson for residents. Keep up on as much as possible!

Regarding billing, this surgeon does a TON of work comp and MVA. Both very good payers were I am.

Thanks for the breakdown on all of this.

 

[IlDestriero]

I think you should do it for free. Being a doctor isnt about making money. Im premed at johns hopkins by the way if it matters.

This is also a good plan. You'll be a real team player.🙄

 

[urge]

Why can't the other guys supervise the crnas? It's not like you are going to be any better than them in your pain office.

 

[Yo GabbaPentin]

Why can't the other guys supervise the crnas? It's not like you are going to be any better than them in your pain office.

Because they want to bill and the CRNA group is not interested in that arrangement.

 

[imfrankie]

I'm not taking responsibility for anyone else's blocks--no way. No way. Intubation, okay, putting in an LMA, okay. Block, no thanks. Whose problem--aside from the patient's--is the prolonged quad weakness, prolonged dysesthesia, etc? Forget that. You got cahones.

 

[IlDestriero]

Fire all of them and start over. Seriously.
The CRNAs want the glory and the pay without the liability (frack that shiite) and the anesthesiologists want all the glory and the loot without the proper skills to do the job.
Time for a system reboot.
The hospital where I work actually did that recently to a problematic arrangement and laid off (fired) a whole bunch of folks. The answer can always be, "NO. This isn't working anymore, or ever really. Goodbye and good luck." Years of headaches gone just like that.
CTRL-ALT-DELETE

 

[NightNight]

Guess I should have been more detailed.

I will be doing some of the blocks but the CRNAs will be doing most of them under ultrasound. They have apparently been doing them for years at another surg. center in an opt out state and had no problems. And here is the sad part. This is an ASC which I have some ownership in. The anesthesia group (3 guys) that I helped get hired has NO REGIONAL EXPERIENCE! I would have to go over an do all of the blocks for them and I have absolutely no time for that. So in this case, the skills which the CRNAs have and anesthesiologists lack, was the reason we brought them in! Important lesson for residents. Keep up on as much as possible!

Regarding billing, this surgeon does a TON of work comp and MVA. Both very good payers were I am.

Thanks for the breakdown on all of this.

Don't want to derail but how is this possible? How can you gradute from residency with no regional experience?

 

[BLADEMDA]

Because they want to bill and the CRNA group is not interested in that arrangement.

Answer: $1,000-$1500 per day. Under $1,000 and you should pass.

Also, does your malpractice cover general OR anesthesia? If not, how much will this cost you?

Finally, you will need a solid legal arrangement that you are simply signing a protocol for CRNA practice and emergency assistance only. Consult an attorney and make sure you are not responsible for any CRNA Regional blocks. Very few CRNAs are truly adept at advanced Regional in my opinion.

 

[BLADEMDA]

Don't want to derail but how is this possible? How can you gradute from residency with no regional experience?

Until the late 1990s many programs didn't do any real regional. That simply doesn't exist today.

So, there are thousands of Anesthesiologists over the age of 40 who suck at regional and had no exposure to ultrasound. Those who finish residency today should be exposed to many types of blocks all performed under u/s.

The world of regional has changed and providers must change with it (as I have done in my practice).

 

[BLADEMDA]

It needs to be a flat fee.

And yes, it can be done.

Supervision is a loose term. Supervision can occur from the golf course or the pain clinic.
Again, flat fee for airway backup is one thing while being the supervisor for nerve blocks is another.

 

[jetproppilot]

Supervision. Again, I am not billing for this. I am the supervising physician as the surgeon does not want to be responsible for anything anesthesia related. Right now they are offering $400.

You're kidding, right?

 

[IlDestriero]

You're kidding, right?

Maybe they mean $400 per patient? 😉

 

[KLPM]

I think you should do it for free. Being a doctor isnt about making money. Im premed at johns hopkins by the way if it matters.

Troll harder.

 

[Yo GabbaPentin]

You're kidding, right?

I wish I was. Obviously that was never a consideration.

 

[sevoflurane]

Yo gabba... Thanks for posting. A thread like this is very useful for those in your situation.
You can def. increase your bottom line... but be careful not to be used.
Eventually, you may want to do pain 100% of the time.
15-20 LESIs per day + some stimulators/pumps days per week is pretty darn lucrative. Just need to build that practice and then give the finger to your orthopod buddy as you pass him in your new Bentley Continental GT...

Nothing is better than beeing your own boss. 🙄

 

[Scylin]

Guess I should have been more detailed.

I will be doing some of the blocks but the CRNAs will be doing most of them under ultrasound. They have apparently been doing them for years at another surg. center in an opt out state and had no problems. And here is the sad part. This is an ASC which I have some ownership in. The anesthesia group (3 guys) that I helped get hired has NO REGIONAL EXPERIENCE! I would have to go over an do all of the blocks for them and I have absolutely no time for that. So in this case, the skills which the CRNAs have and anesthesiologists lack, was the reason we brought them in! Important lesson for residents. Keep up on as much as possible!

Regarding billing, this surgeon does a TON of work comp and MVA. Both very good payers were I am.

Thanks for the breakdown on all of this.

Any particular reason you chose to hire CRNAs for regional rather than newer anesthesiologist grads with the regional training, other than CRNAs are cheaper? I'm not trying to be obnoxious, I'm just trying to understand the general employment situation for recent grads a bit better. I'll be starting residency this year so these issues are something I want to keep an eye on as I complete my training...

 

[Direct Laryngoscopy]

Any particular reason you chose to hire CRNAs for regional rather than newer anesthesiologist grads with the regional training, other than CRNAs are cheaper? I'm not trying to be obnoxious, I'm just trying to understand the general employment situation for recent grads a bit better. I'll be starting residency this year so these issues are something I want to keep an eye on as I complete my training...

You will learn that in the business of medicine, it always about the dollar (at least most of the time).

 

[Scylin]

You will learn that in the business of medicine, it always about the dollar (at least most of the time).

Yeah, I figured that was the reason, which is why I was asking if there was any other factor on top of the money.

 

[pgg]

The anesthesia group (3 guys) that I helped get hired has NO REGIONAL EXPERIENCE!

For some reason this reminds me of a place where I interviewed when I was still feeling out nearby locums/moonlighting jobs. I'm being led around, meeting the group. "This is Dr ____, he can do TIVAs. Do you know how to do that?" I was sort of confused, wondering if this was some kind of trick question, but said yes or sure or something else affirmative. They were all atwitter, like this was an uncommon skill.

Never did work there. They lost their contract to some AMC a couple years ago.



Nothing else to add except $400 is far too small a piece of the pie to put my name on someone else's chart, physician or CRNA. I wouldn't do it for the whole pie either, unless I was doing the blocks myself and directing their care. I've done my share of fireman duty and it sucks, but at least I'm not on the hook for anyone else's complications, I'm just an available consultant.

 

[Oggg]

+1 to reboot.

 

[jwk]

I have recently been offered a role supervising two CRNAs at a surgery center. This is one day a week for a surgeon who brings their own CRNAs. The surgeon does not want to be the supervising physician, so it has been offered to me. 90% + of all cases are regional + IV sedation/MAC. I will be getting cases started early and then doing my own cases (pain management).

The CRNAs are part of a group and will bill for the services. This is just the way it has to be, as this is the group that the surgeon requires.

So my question is, how much to I charge this CRNA group for my services? PM's would also be welcome.

And leave politics out of it. I helped to make sure that two anesthesiologists got the contract for the other 4 days a week.

Do the CRNA's work for the surgeon? You say he brings his own CRNAs, which is what that kind of implies. Or does he simply specify that this is who he wants doing the anesthesia for his cases? If he's actually their employer, he can't pass off the supervision responsibilities to someone else - respondeat superior would apply.

What happens if you don't agree to this arrangement? Is he going to take his business elsewhere?

 

[Yo GabbaPentin]

Yo gabba... Thanks for posting. A thread like this is very useful for those in your situation.
You can def. increase your bottom line... but be careful not to be used.
Eventually, you may want to do pain 100% of the time.
15-20 LESIs per day + some stimulators/pumps days per week is pretty darn lucrative. Just need to build that practice and then give the finger to your orthopod buddy as you pass him in your new Bentley Continental GT...

Nothing is better than beeing your own boss. 🙄

I actually do practice pain full time but am part of a group and am not a partner yet. The orthopod is by FAR collecting more than anyone else combined for the ASC so keeping him happy is important. He is the one requesting the CRNA group who hustles around and apparently does have good regional skills. The anesthesiologists have been let go from other clinics for various reasons.

This is about a little more than money for me. I would like to keep my toes in the shallow end of the pool in regards to anesthesia. Just not willing to get raped in the process.

Thanks for all of the help!

 

[ctsicu]

Kind of a sickening thread. Can't believe that you can't find doctors to do their stuff. I don't see how doing this is going to keep your toes in anesthesia. Seems like all you're doing is signing to get all the liability and none of the pie. I would charge at LEAST 2k

 

[urge]

Kind of a sickening thread. Can't believe that you can't find doctors to do their stuff.

I don't really think that is the issue. I imagine this is an opt out state. Seems to me that the orthopod hired two salaried nurses and plans on keeping their billing. He is looking for an anesthesiologist to bail out such nurses if it goes bad. It's all off the record. He probably doesn't want a real supervising anesthesiologist in order not to lose half money he is making form the nursing billing.

The whole thing is fishy. I'm not sure about liability for cases gone wrong. You just "happen to be" an anesthesiologist who answered a distress call.

 

[Arch Guillotti]

Supervision. Again, I am not billing for this. I am the supervising physician as the surgeon does not want to be responsible for anything anesthesia related. Right now they are offering $400.

I'm a little confused here. Are you supervising or directing?

 

[IlDestriero]

The whole thing is fishy. I'm not sure about liability for cases gone wrong. You just "happen to be" an anesthesiologist who answered a distress call.

But that's not what they want, they want him to supervise from the pain clinic, and supply the malpractice barrier. The ortho surgeon used to supervise. At least that's what it sounds like. They want a fall guy, not a fireman.

 

[Yo GabbaPentin]

But that's not what they want, they want him to supervise from the pain clinic, and supply the malpractice barrier. The ortho surgeon used to supervise. At least that's what it sounds like. They want a fall guy, not a fireman.

Bingo. Might not do it at all. Anyone looking for an ASC gig? 🙂

 

[Planktonmd]

I think you should do it for free. Being a doctor isnt about making money. Im premed at johns hopkins by the way if it matters.

 

[dhb]

I thought the comment was hilarious

 

[Mman]

But that's not what they want, they want him to supervise from the pain clinic, and supply the malpractice barrier. The ortho surgeon used to supervise. At least that's what it sounds like. They want a fall guy, not a fireman.

And I wouldn't touch it with a 10 foot pole. Ortho guy flying through as many cases as he can in a day with 2 CRNAs banging them out rapid fire including blocks without supervision means there is going to be malpractice and their will be lawsuits over a long enough time frame.

You don't want to be named in suits as supervising potentially crappy care that you had nothing to do with.

The sad part of the situation is that the money generated by anesthesia services in such a situation (all private payers) would be infinitely higher with an anesthesiologist supervising and billing for it compared to just CRNAs billing for their part. Insurance companies pay far higher rates for the MD portion than the CRNA portion.

I suspect the surgeon just wants to maintain the ability to have the CRNAs answer to him (or her) and not get cases cancelled by an anesthesiologist if they aren't appropriate.

 

[ssmallz]

And I wouldn't touch it with a 10 foot pole. Ortho guy flying through as many cases as he can in a day with 2 CRNAs banging them out rapid fire including blocks without supervision means there is going to be malpractice and their will be lawsuits over a long enough time frame.

You don't want to be named in suits as supervising potentially crappy care that you had nothing to do with.

The sad part of the situation is that the money generated by anesthesia services in such a situation (all private payers) would be infinitely higher with an anesthesiologist supervising and billing for it compared to just CRNAs billing for their part. Insurance companies pay far higher rates for the MD portion than the CRNA portion.

I suspect the surgeon just wants to maintain the ability to have the CRNAs answer to him (or her) and not get cases cancelled by an anesthesiologist if they aren't appropriate.

Agree completely. There's plenty of money in this arrangement to hire 2 anesthesiologists or 1 anesthesiologist to block and supervise. This orthopod sounds like a greedy bastard and your anesthesia buddies sound pretty terrible, neither one is worth you being a malpractice fall guy for. I would only do this if I were doing the blocks myself and had complete control of what goes into the OR and what gets canceled. This sounds like a no win situation for you. Agree w/Jet, F the anesthesia portion of this and focus on the pain clinic. Supervising CRNAs doing knee scopes isn't gonna keep up your anesthesia skills any more than doing blocks in your pain clinic will.

 

[Yo GabbaPentin]

Can I bill for the blocks if I show up early and knock out five or six blocks before clinic? That way maybe I can teach the anesthesiologists some new tricks, avoid the Crna group and not waste my time? Are the blocks bundled in any way into the anesthesia?

 

[IlDestriero]

You can bill for blocks if you're consulted for the block for post op pain control. If the anesthetic is a block and Mac, I think you're SOL.

 

[Yo GabbaPentin]

Do the anesthesiologists get paid MORE for doing the case under regional? Sorry for all the billing questions. I'd just like to help out without putting my ***** on the line. Also wouldn't mind making a couple extra dollars to pay off my damn student loans.