"When your practice owns 100% of the ASC" question...

[ErrantWhatever]

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If the PP you work for or are considering owns 100% of the ASC, and no partners of the PP are individual shareholders of the ASC--access to revenue from the facility fees is bundled into partnership of the practice itself--then why shouldn't facility fees be counted toward your bonus structure? This is particularly if the practice is requiring you to do everything in the ASC.

Just wondering what others' thoughts might be. Appreciate any input.

 

[CleanUp]

It should be.

If not, then leave.

I was a sucker for long time. Finally I saw what kind of facilities fees they were bringing in and how many ancillary incomes I produced.

Annnnnd I bet they’re giving a nice stipend/bonus/whatever to some senior partner who acts as a medical director.

 

[gdub25]

if the practice owns the ASC and not individual docs, then yes, the facility fees are income into the practice. If the practice is taxed as a partnership then the income of the practice can be distributed however the partners decide which means the facility fees can be divided up to the docs who are producing them. This is not a typical ASC structure but one I have explored heavily and am actively working on as it gives a lot of incentive for a new doc coming in to reap the rewards of ASC without hassles or the buy in.

 

[BoardingDoc]

if the practice owns the ASC and not individual docs, then yes, the facility fees are income into the practice. If the practice is taxed as a partnership then the income of the practice can be distributed however the partners decide which means the facility fees can be divided up to the docs who are producing them. This is not a typical ASC structure but one I have explored heavily and am actively working on as it gives a lot of incentive for a new doc coming in to reap the rewards of ASC without hassles or the buy in.

That system also seems inherently more egalitarian. One thing with ASCs that I don't fully understand is how to assess their relative value when shares are owned by non operating partners, or low revenue generating partners.

To clarify: I see a scenario where there are 10 docs who own 1 share each. Each one does procedures in the ASC. The money is divided evenly. How does one deal with a scenario where Doc A is 2x as productive as the next doc? I assume that Doc A gets the same ASC payout as he owns the same number of shares as everyone else. What's the incentive for doc A to keep working that hard?

Similarly, you buy into an ASC with 10 owners but only 3 of them are doing procedures there. Effectively there are 3 workhorses supporting the income of themselves plus 7 passive investors?

I'm curious how scenarios like that are addressed. Or if I am grossly misunderstanding things, I would love to learn more.

 

[gdub25]

There are no good ways to handle what you describe in the traditional model of each doctor owning as individual. Profits must be distributed pro rata to their ownership. The operating agreement almost always stipulates that ownership must be given up if the doctor is not actively involved in the practice of medicine but there are plenty of examples of older docs who will still do a few cases per month to satisfy that requirement and continue to leech money.

Pain management is an especially difficult specialty to deal with these issues because we don't need an OR for the most part with the vast majority of what we do being able to be done in our offices. Compare us to ortho for example. They make their mo eh in the OR on professional fees. They are going to be in the OR regardless if they have ownership or not so having any amount of ownership and getting any amount of facility fees is always going to be a bonus for them. For us, we are always going to being doing math to see if the facility distributions we get are are making up for the reduction in pro fee we lose for leaving the office.

 

[Dr. Ice]

There are no good ways to handle what you describe in the traditional model of each doctor owning as individual. Profits must be distributed pro rata to their ownership. The operating agreement almost always stipulates that ownership must be given up if the doctor is not actively involved in the practice of medicine but there are plenty of examples of older docs who will still do a few cases per month to satisfy that requirement and continue to leech money.

Pain management is an especially difficult specialty to deal with these issues because we don't need an OR for the most part with the vast majority of what we do being able to be done in our offices. Compare us to ortho for example. They make their mo eh in the OR on professional fees. They are going to be in the OR regardless if they have ownership or not so having any amount of ownership and getting any amount of facility fees is always going to be a bonus for them. For us, we are always going to being doing math to see if the facility distributions we get are are making up for the reduction in pro fee we lose for leaving the office.

This is spot on..

 

[nvrsumr]

I didn’t even know you could set up asc ownership this way. Always learn something on sdn

 

[RoloTomassi]

Same, I thought the reason it had to be the typical way is Stark

 

[ErrantWhatever]

Apparently if you structure it appropriately, there’s no Stark violation. I’ve run into a few groups doing it this way lately. The rationale from one group was that this approach was chosen to assist with overhead/expenses of the practice in our era of decreasing pro fees. It also can encourage various partners to bring the majority of their procedures to the practice’s ASC.

 

[Dr. Ice]

I’m looking into entering an agreement with a hospital system that currently also is the majority shareholder of my asc. Rvu model, majority of procesures done in office, but hopefully able to provide enough cases to the asc to maintain my shareholder status i in the asc without having to worry about pp collections and clearing overhead, plus the benefits of hospital employment, ie vacation, staffing, etc

 

[BobBarker]

See and hear about that model frequently of late. It allows you to double dip that chip on the facility side.

 

[gdub25]

Same, I thought the reason it had to be the typical way is Stark

At a very technical level, Stark actually doesn't apply at all to surgery centers. I don't quite understand the ins and outs of it so I can't explain much, but have seen a healthcare law firm advising on a 100 million dollar deal where this has been discussed.

What I've found is that much of the time things are done a certain way simply because that's how everyone else has been doing it and no one ever thought of doing it differently.

 

[masterPain]

If the PP you work for or are considering owns 100% of the ASC, and no partners of the PP are individual shareholders of the ASC--access to revenue from the facility fees is bundled into partnership of the practice itself--then why shouldn't facility fees be counted toward your bonus structure? This is particularly if the practice is requiring you to do everything in the ASC.

Just wondering what others' thoughts might be. Appreciate any input.

Are you RVU based? Define “bonus structure”

 

[ErrantWhatever]

Nope, not RVU-based. Base salary + 50% collections over 2x base.

So by “bonus structure,” I’m asking why should only my clinic E&M collections + ASC pro fees (on average 30-40% of my total monthly collections) only be counted toward my bonus and not the facility fee also, when the ASC is an extension of the practice itself.

 

[masterPain]

That’s a tough one. I can see both sides but let me play devils advocate. This isn’t common practice in the hosptial setting unless the individual owns equity in the hosptial. I would guess you getting this proportion of the facility fee would give you a massive salary (far above FMV) and eat into the owners profit margins who invested a significant amount of money into the facility.

My recommendation is to negotiate and find a middle ground.

 

[NVO]

Nope, not RVU-based. Base salary + 50% collections over 2x base.

So by “bonus structure,” I’m asking why should only my clinic E&M collections + ASC pro fees (on average 30-40% of my total monthly collections) only be counted toward my bonus and not the facility fee also, when the ASC is an extension of the practice itself.

What is your % collections of the ASC pro fees? Is it still 50%?

 

[BoardingDoc]

What is your % collections of the ASC pro fees? Is it still 50%?

This is the right question. You're not going to get a cut of ASC facility fees except as an owner, or unless you're paid by RVU and there's some cut built into that math.

That said, if your collections are purely office E+M and ASC pro fees, I would expect that you're getting 100% (or very near that if the ASC is poorly run) of those ASC pro fee collections, and they keep the facility fees.

Context: If you were in PP and keeping 50% of your collections here's an example
LESI (62321) in office pays ~$252 in office
50% of that is $126

LESI in ASC (PRO FEES) pays ~$104
50% of that is $52

 

[masterPain]

This is the right question. You're not going to get a cut of ASC facility fees except as an owner, or unless you're paid by RVU and there's some cut built into that math.

That said, if your collections are purely office E+M and ASC pro fees, I would expect that you're getting 100% (or very near that if the ASC is poorly run) of those ASC pro fee collections, and they keep the facility fees.

Context: If you were in PP and keeping 50% of your collections here's an example
LESI (62321) in office pays ~$252 in office
50% of that is $126

LESI in ASC (PRO FEES) pays ~$104
50% of that is $52

Wouldn’t they deduct expenses prior to paying 50% collections?

 

[masterPain]

It should be.

If not, then leave.

I was a sucker for long time. Finally I saw what kind of facilities fees they were bringing in and how many ancillary incomes I produced.

Annnnnd I bet they’re giving a nice stipend/bonus/whatever to some senior partner who acts as a medical director.

^^^ doesn’t understand the business of medicine. (Or business in general)

Everyone thinks it’s easy till they try it themselves. You have the luxury showing up day one with a full schedule and get paid a large salary with a % of everything you touch. The building is paid for, the office is staffed, and the c arm is warmed up ready to go.

The senior partner probably started the practice, invested millions, and has decades of sweat equity.
Not to mention they carry ALL the risk and exposure. You might get sued for med malpractice (to which you have insurance) but they have all the general liability.

I’m sure said practice had a toxicology lab. The analyzers were probably 500k plus. Why should you get the ancillary income when you paid 0$ for the ancillary? I’m not saying you shouldn’t get a proportion of it.

Speaking from personal experience, its not easy to build, own, and operate an ASC. And it’s mega expensive with small margins. That why there’s a thing called FMV that allows you to buy in. Hence, the value of the business that has been built before you showed up on the scene.

I like to compare this to law firms. Associates work like dogs to make partner and share in the overall revenue of the firm. This doesn’t mean they own it for life.

If you wanna share in all those things then buy in just like every other business in the world. If you work for NVDIA as a programmer they don’t just give you stock bc you’re “special”. You have to buy it just like everyone else. They probably get preferred stock options as an employee just like doctors are offered reduced multiples to buy in when compared to private equity.

 

[masterPain]

Nope, not RVU-based. Base salary + 50% collections over 2x base.

So by “bonus structure,” I’m asking why should only my clinic E&M collections + ASC pro fees (on average 30-40% of my total monthly collections) only be counted toward my bonus and not the facility fee also, when the ASC is an extension of the practice itself.

another thing you can do is renegotiate your contract on RVU basis. This structure indirectly gives you part of facility fee. How employed docs at hospitals do it. (Can’t own equity as employee must be independent)

 

[BoardingDoc]

Wouldn’t they deduct expenses prior to paying 50% collections?

They should absolutely be deducting expenses. In an office setting, that can be around 50-60% which is why we see a lot of people posting offers where they get to keep 40-50% of their collections.

In an ASC setting, I would expect the expenses to be built into the facility fee component as that reimbursement is generally much higher than the pro fee reimbursement. It is also literally the fee designed to pay for said expenses.

As I alluded to, they might want to cut into the pro fees as well if the ASC isn't well run (high fixed costs without enough volume to offset it for example), though that seems more of a red flag than a valid excuse (within a reasonable margin. What that margin is, I don't have a great answer for).

To be clear, I'm not saying that people don't post offers where they say they are getting 50% of collections from their ASC pro fees. They do. I'm saying that those offers suck, and they should be doing their procedures in office instead, or renegotiating what their pro-fee take from the ASC is.

 

[masterPain]

They should absolutely be deducting expenses. In an office setting, that can be around 50-60% which is why we see a lot of people posting offers where they get to keep 40-50% of their collections.

In an ASC setting, I would expect the expenses to be built into the facility fee component as that reimbursement is generally much higher than the pro fee reimbursement. It is also literally the fee designed to pay for said expenses.

As I alluded to, they might want to cut into the pro fees as well if the ASC isn't well run (high fixed costs without enough volume to offset it for example), though that seems more of a red flag than a valid excuse (within a reasonable margin. What that margin is, I don't have a great answer for).

To be clear, I'm not saying that people don't post offers where they say they are getting 50% of collections from their ASC pro fees. They do. I'm saying that those offers suck, and they should be doing their procedures in office instead, or renegotiating what their pro-fee take from the ASC is.

Refreshing to hear other physicians whom understand revenue cycle. The new grads think everyone is out to get them. There is value not being required to deal with the headache of running a business. Anesthesia management companies get paid for a reason.

Funniest part is some think owning and operating a practice is the holy grail. We too only get paid 50% of everything we do. Moreover, think about the massive amount of things we DONT get paid on that we write off. Deductibles, 20% uncovered patient balances, and down right insurance fraud by the big boys.

 

[gdub25]

Refreshing to hear other physicians whom understand the revenue cycle. The new grads think everyone is out to get them. There is value is not being required to deal with the headache of running a business. Anesthesia management companies get paid for a reason.

Funniest part is some think owning and operating a practice is the holy grail. We too only get paid 50% of everything we do. Moreover, think about the massive amount of things we DONT get paid on that we write off. Deductibles, 20% uncovered patient balances, and down right insurance fraud by the big boys.

I literally had a guy apply last week to a job posting I have. He was in private practice for 8 years, apparently couldn't make it work and gave up to go work as a hospital employed doc 1.5 years ago. Hears about our deal in which he'd make more money but then wants to know "more about the overhead, what percentage of the collections are contributing to his salary, partnership buy in, ect". Went all over me. The dude couldn't make it on his own but out of the gate wants to get his piece of ownership in what we've built and asking questions about overhead and his percentage of collections because he doesn't want anyone making money off of him even though he'd be making 30% more with us than his current job.

I really thought someone who had tried and failed at private practice would understand our position on the ownership side better.

 

[masterPain]

I see physicians in private practice fail all the time, especially these days. Why do you think there been a massive shift towards employed physicians vs independence the past decade?

Few will put in 40-50 hours clinically followed by another 20-30 on nights and weekends to build/maintain a practice. If you don’t obsessively watch everything it will crater. The only way to achieve such is burnout. Pick your poison. Be controlled by your employer or your practice. No free rides.

 

[CleanUp]

^^^ doesn’t understand the business of medicine. (Or business in general)

Everyone thinks it’s easy till they try it themselves. You have the luxury showing up day one with a full schedule and get paid a large salary with a % of everything you touch. The building is paid for, the office is staffed, and the c arm is warmed up ready to go.

The senior partner probably started the practice, invested millions, and has decades of sweat equity.
Not to mention they carry ALL the risk and exposure. You might get sued for med malpractice (to which you have insurance) but they have all the general liability.

I’m sure said practice had a toxicology lab. The analyzers were probably 500k plus. Why should you get the ancillary income when you paid 0$ for the ancillary? I’m not saying you shouldn’t get a proportion of it.

Speaking from personal experience, its not easy to build, own, and operate an ASC. And it’s mega expensive with small margins. That why there’s a thing called FMV that allows you to buy in. Hence, the value of the business that has been built before you showed up on the scene.

I like to compare this to law firms. Associates work like dogs to make partner and share in the overall revenue of the firm. This doesn’t mean they own it for life.

If you wanna share in all those things then buy in just like every other business in the world. If you work for NVDIA as a programmer they don’t just give you stock bc you’re “special”. You have to buy it just like everyone else. They probably get preferred stock options as an employee just like doctors are offered reduced multiples to buy in when compared to private equity.

My friend, I applaud you with your efforts however, please let me clarify

1. The senior partners took out a loan and did not disclose it to other people. It accrued interest over 25+ years. They sold parts of the asc to pay off this loan and stuck the left holding the bag.
2. The group broke HIPAA laws with local centers and are currently undergoing a lawsuit in which they will be spending time in prison and paying a fee.
3. The group was also found to be billing incorrectly. Thus there is an outstanding Medicare fraud claim.
4. No toxicology lab. The previous senior partner would start patients on opioids and then would refer them to his own addiction rehab facility. This is legal by the way.

5. Funny you bring up NVDIA. I have had a tremendous amount of luck through no skill of my own and got in very early for two startups. And thus my desire to volunteer my clinical skills.

Overall, I agree with you those owners who take the start up risk deserve the majority of income. I am not arguing that. What I am advocating for is if someone else brings an ancillary income and helps the business grow then they are entitled to a fair and reasonable amount of profits.

Since you are the business man, I know that you know that the EBIDTA of medical practices without equipment is little to nothing. Without the “good will” and physicians there is no real multiplier. This is not a SaaS business that can scale.

I currently employee 18 physicians. I pay them an above market rate. I market for them. I provide ample support for new graduates. The cme stipend is way above market value. Some are able to retire early because of this. My ancillary staff is extremely well supported. Instead of yelling at them like the previous practice I spent an extremely generous amount of time with them daily, making sure that they understand the tasks. They get bonuses.

Do the other physicians share the upside potential? No. Because like you said, they did not take the financial risk however they are compensated fairly. There are no shady backroom deals. Everything is transparent. I work hard to keep cost extremely low and quality high.

PM if you’d like more details.

 

[masterPain]

My friend, I applaud you with your efforts however, please let me clarify

1. The senior partners took out a loan and did not disclose it to other people. It accrued interest over 25+ years. They sold parts of the asc to pay off this loan and stuck the left holding the bag.
2. The group broke HIPAA laws with local centers and are currently undergoing a lawsuit in which they will be spending time in prison and paying a fee.
3. The group was also found to be billing incorrectly. Thus there is an outstanding Medicare fraud claim.
4. No toxicology lab. The previous senior partner would start patients on opioids and then would refer them to his own addiction rehab facility. This is legal by the way.

5. Funny you bring up NVDIA. I have had a tremendous amount of luck through no skill of my own and got in very early for two startups. And thus my desire to volunteer my clinical skills.

Overall, I agree with you those owners who take the start up risk deserve the majority of income. I am not arguing that. What I am advocating for is if someone else brings an ancillary income and helps the business grow then they are entitled to a fair and reasonable amount of profits.

Since you are the business man, I know that you know that the EBIDTA of medical practices without equipment is little to nothing. Without the “good will” and physicians there is no real multiplier. This is not a SaaS business that can scale.

I currently employee 18 physicians. I pay them an above market rate. I market for them. I provide ample support for new graduates. The cme stipend is way above market value. Some are able to retire early because of this. My ancillary staff is extremely well supported. Instead of yelling at them like the previous practice I spent an extremely generous amount of time with them daily, making sure that they understand the tasks. They get bonuses.

Do the other physicians share the upside potential? No. Because like you said, they did not take the financial risk however they are compensated fairly. There are no shady backroom deals. Everything is transparent. I work hard to keep cost extremely low and quality high.

PM if you’d like more details.

There’s always more to the story. Sounds like a real sh** show.

Define “bringing ancillary income”. Did you create the ancillary or just benefit from it (ie already established) by seeing the patients? (At the time)

How did you grow their practice? Are you sure it was you or was it just organic growth of the business? (At the time)

Sounds like you went out on your own and started your own thing, I applaud you!! Not easy was it? Especially if you are employing 18 docs it’s a massive operation.

Do you do any clinical work presently?

 

[ErrantWhatever]

I completely respect any physician entrepreneur who starts a PP, particularly in our era, and believe they should get what is due for taking the risks of starting and maintaining the practice.

My initial inquiry focuses on this traditional distinction between practice-guaranteed salary and facility fees from the ASC, a separate entity with individual shareholders. When the ASC no longer is a completely separate entity but is a subsidiary of the practice itself, at times explicitly in order to support the practice as an ancillary revenue stream, then what now is the rationale for limiting the employed physician’s salary and bonus structure to clinic and pro fee revenue? The sharp lines become blurred. This is highlighted further when those facility fees constitute 60-70% (or more) of what the physician generates for the practice.

It seems the OIG weighed in on a specific instance of this in October, 2023.

OIG Approves Net Profit–Based Bonuses for Employed Physicians – Publications

 

[RoloTomassi]

I completely respect any physician entrepreneur who starts a PP, particularly in our era, and believe they should get what is due for taking the risks of starting and maintaining the practice.

My initial inquiry focuses on this traditional distinction between practice-guaranteed salary and facility fees from the ASC, a separate entity with individual shareholders. When the ASC no longer is a completely separate entity but is a subsidiary of the practice itself, at times explicitly in order to support the practice as an ancillary revenue stream, then what now is the rationale for limiting the employed physician’s salary and bonus structure to clinic and pro fee revenue? The sharp lines become blurred. This is highlighted further when those facility fees constitute 60-70% (or more) of what the physician generates for the practice.

It seems the OIG weighed in on a specific instance of this in October, 2023.

OIG Approves Net Profit–Based Bonuses for Employed Physicians – Publications

That's very interesting, new info to me. Seems like OIG is saying employees can get a cut of facility fees, regardless of whether separate entity or funnels to practice.

But for your situation, it really doesn't matter which pot the money comes from, does it? They believe that fair reimbursement is "Base salary + 50% collections over 2x base" with that collections being E&M and ASC pro fees.

If you don't think that is fair then ask for a higher % of that. You could otherwise ask for the collections to include the facility fee but they'll just lower the %. They'll do the math to make it the same $ for the same amount of labor.

 

[masterPain]

I completely respect any physician entrepreneur who starts a PP, particularly in our era, and believe they should get what is due for taking the risks of starting and maintaining the practice.

My initial inquiry focuses on this traditional distinction between practice-guaranteed salary and facility fees from the ASC, a separate entity with individual shareholders. When the ASC no longer is a completely separate entity but is a subsidiary of the practice itself, at times explicitly in order to support the practice as an ancillary revenue stream, then what now is the rationale for limiting the employed physician’s salary and bonus structure to clinic and pro fee revenue? The sharp lines become blurred. This is highlighted further when those facility fees constitute 60-70% (or more) of what the physician generates for the practice.

It seems the OIG weighed in on a specific instance of this in October, 2023.

OIG Approves Net Profit–Based Bonuses for Employed Physicians – Publications

Here’s the sticking point for me. Does it make a difference to you if you do an RFA in the clinic or ASC? No, the procedure is what it is.

Your problem is the PRACTICE makes more money not really what you’re personally doing. Envy is one of my biggest pet peeves. IMO if you want a piece of the facility fee you should pay for it just like everyone else.

I think the solution to your problem is renegotiating a RVU based package.

I totally understand your frustration and you worked your tail off to get where you are. The OIG thing is interesting but would be a colossal disaster for all HOPDs/ASCs

 

[NVO]

Here’s the sticking point for me. Does it make a difference to you if you do an RFA in the clinic or ASC? No, the procedure is what it is.

Your problem is the PRACTICE makes more money not really what you’re personally doing. Envy is one of my biggest pet peeves. IMO if you want a piece of the facility fee you should pay for it just like everyone else.

I think the solution to your problem is renegotiating a RVU based package.

I totally understand your frustration and you worked your tail off to get where you are. The OIG thing is interesting but would be a colossal disaster for all HOPDs/ASCs

But it does make a difference because its not the fact that the practice makes more money, but he makes LESS money if he were to do it in the ASC rather than the clinic.

 

[RoloTomassi]

But it does make a difference because its not the fact that the practice makes more money, but he makes LESS money if he were to do it in the ASC rather than the clinic.

Then he should find a clinic based job that offers the same compensation formula. Or negotiate this one up. Because asking for 50% facility fee collections is probably more than the percentage of collections the partners take home.

 

[masterPain]

But it does make a difference because its not the fact that the practice makes more money, but he makes LESS money if he were to do it in the ASC rather than the clinic.

That was my point in a round about way. He’s not entitled to the facility fees imo so needs to restructure as RVU.

Or have a correction factor for the cases he does in the ASC to reflect what he would otherwise make in the clinic.

Like I said above, meet with them and negotiate a resolution. The answer isn’t getting the facility fee.

 

[masterPain]

Then he should find a clinic based job that offers the same compensation formula. Or negotiate this one up. Because asking for 50% facility fee collections is probably more than the percentage of collections the partners take home.

Exactly

 

[MitchLevi]

Did someone ask for 50% of the facility fee? That’s crazy…

I think most doctors who aren’t seeing facility fee numbers believe they’re just churning gobs of money out like a sausage maker.

 

[ErrantWhatever]

Did someone ask for 50% facility fee?

 

[RoloTomassi]

Did someone ask for 50% facility fee?

I thought you were but apparently I misunderstood.

Base salary + 50% collections over 2x base.

So by “bonus structure,” I’m asking why should only my clinic E&M collections + ASC pro fees (on average 30-40% of my total monthly collections) only be counted toward my bonus and not the facility fee also

 

[NVO]

That was my point in a round about way. He’s not entitled to the facility fees imo so needs to restructure as RVU.

Or have a correction factor for the cases he does in the ASC to reflect what he would otherwise make in the clinic.

Like I said above, meet with them and negotiate a resolution. The answer isn’t getting the facility fee.

Agreed, would never ask for facility fees. Simplest way would be to ask for higher % pro fee for procedures done at the ASC. Even then you're probably behind compared to doing them in clinic

 

[masterPain]

Agreed, would never ask for facility fees. Simplest way would be to ask for higher % pro fee for procedures done at the ASC. Even then you're probably behind compared to doing them in clinic

Should be easy convo. If I owned the clinic I’d do it instantaneously.

It’s this simple, pay me the same for RFA in ASC as you do for me in clinic. (Or any other procedure)

They’re making more in the ASC absolutely no logical reason to not accommodate request.

Done

 

[Ducttape]

Nope, not RVU-based. Base salary + 50% collections over 2x base.

So by “bonus structure,” I’m asking why should only my clinic E&M collections + ASC pro fees (on average 30-40% of my total monthly collections) only be counted toward my bonus and not the facility fee also, when the ASC is an extension of the practice itself.

the facility fee is normally not what you do as a physician work wise. we get wRVU. a total RVU is wRVU + malpractice RVU + practice expense RVU.


if you ask for part of facility fee, wouldnt you be double dipping - getting profits from owning the ASC and then getting payment from facility fees?

additionally, no idea if this would this be a Stark violation

 

[MitchLevi]

the facility fee is normally not what you do as a physician work wise. we get wRVU. a total RVU is wRVU + malpractice RVU + practice expense RVU.


if you ask for part of facility fee, wouldnt you be double dipping - getting profits from owning the ASC and then getting payment from facility fees?

additionally, no idea if this would this be a Stark violation

We just lost our busiest and most productive guy in our group to a competitor who was able to pay him far bigger amounts of money through the ASC, and our attorneys apparently could not figure out how they’re doing it, but I would bet it is this exact mechanism.

You get ownership in the ASC with dividends, AND a small percentage of the facility fee itself. Even if that is just 10% of the facility fee for example, it would add up quickly if you’re doing super high numbers of total hips and knees.

 

[BobBarker]

@MitchLevi if he has a percentage ownership (5% guessing. Gets very expensive for higher amounts for an established ASC) and then is on rvu that would be a legal way to get him more money for his productivity. You can’t give him an additional percentage of the facility fee. They might also be giving him a directorship position with maybe $50,000 maximum for that.

 

[MitchLevi]

@MitchLevi if he has a percentage ownership (5% guessing. Gets very expensive for higher amounts for an established ASC) and then is on rvu that would be a legal way to get him more money for his productivity. You can’t give him an additional percentage of the facility fee. They might also be giving him a directorship position with maybe $50,000 maximum for that.

It isn’t directorship and the difference is apparently 6 figures. I don’t get it. It was thoroughly vetted by our attorneys who could not figure it out. The consensus was that it felt illegal.

 

[BoardingDoc]

@MitchLevi if he has a percentage ownership (5% guessing. Gets very expensive for higher amounts for an established ASC) and then is on rvu that would be a legal way to get him more money for his productivity. You can’t give him an additional percentage of the facility fee. They might also be giving him a directorship position with maybe $50,000 maximum for that.

Couldn't you just be hired by the group who owns the ASC and they choose to pay you like a HOPD? E.g. 70/wrvu or something and not based on collections?

 

[BobBarker]

Yes, certainly. By giving some ownership, you have more incentive to bring cases that pay better however.

 

[gdub25]

Should be easy convo. If I owned the clinic I’d do it instantaneously.

It’s this simple, pay me the same for RFA in ASC as you do for me in clinic. (Or any other procedure)

They’re making more in the ASC absolutely no logical reason to not accommodate request.

Done

Yes, certainly. By giving some ownership, you have more incentive to bring cases that pay better however.

This while model of the practice owning the ASC in its entirety and then paying the docs out of the profits that come through the practice is exactly what I have set out to do. Using small amounts of ASC ownership to lock guys in and then trying to find ways to incentivize them to keep coming and producing is a failed approach. Also, as Bob pointed out, getting someone to come and buy in to an existing facility is very expensive, several hundred thousand per share in some instances.


In our current working model, if I build a new Surgery center and the practice owns it, I can hire an employed doctor and they can get paid based on RVU and I would be able to pay them a healthy portion of clinic collections and ASC collections on both the professional and facility side so that in the end they make double what a hospital would pay them and I still make money.

 

[ErrantWhatever]

This while model of the practice owning the ASC in its entirety and then paying the docs out of the profits that come through the practice is exactly what I have set out to do. Using small amounts of ASC ownership to lock guys in and then trying to find ways to incentivize them to keep coming and producing is a failed approach. Also, as Bob pointed out, getting someone to come and buy in to an existing facility is very expensive, several hundred thousand per share in some instances.


In our current working model, if I build a new Surgery center and the practice owns it, I can hire an employed doctor and they can get paid based on RVU and I would be able to pay them a healthy portion of clinic collections and ASC collections on both the professional and facility side so that in the end they make double what a hospital would pay them and I still make money.

You hiring?

 

[RoloTomassi]

This while model of the practice owning the ASC in its entirety and then paying the docs out of the profits that come through the practice is exactly what I have set out to do. Using small amounts of ASC ownership to lock guys in and then trying to find ways to incentivize them to keep coming and producing is a failed approach. Also, as Bob pointed out, getting someone to come and buy in to an existing facility is very expensive, several hundred thousand per share in some instances.


In our current working model, if I build a new Surgery center and the practice owns it, I can hire an employed doctor and they can get paid based on RVU and I would be able to pay them a healthy portion of clinic collections and ASC collections on both the professional and facility side so that in the end they make double what a hospital would pay them and I still make money.

Sounds great for your employees but you must be running incredibly low overhead to be able to pay this well and still profit. If HOPD pays 65/wRVU, you're talking about 130/wRVU? 1.3M for 10k wRVUs would be a dream job.

 

[BobBarker]

no. 15000 rvu minimum.

 

[Ducttape]

i cannot see how such an ASC would be profitable...

you still would have to, at reduced income, have to pay for the facility itself, nurses, techs, rad techs, administrative staff, etc.

 

[nvrsumr]

I currently employee 18 physicians. I pay them an above market rate.

some baller docs on sdn. Good for you