Will i ever get a pay raise?

[chillaxbro]

I’m a new attending, I’m looking up salaries of other attendings who have been working like 15-20 years and they all get paid the same as me as a new grad. Do EM docs not get pay raises? Even with work experience? We’re salaried at an academic place. Am I destined to make the same salary for the rest of my life?

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[Jabbed]

I’m a new attending, I’m looking up salaries of other attendings who have been working like 15-20 years and they all get paid the same as me as a new grad. Do EM docs not get pay raises? Even with work experience? We’re salaried at an academic place. Am I destined to make the same salary for the rest of my life?

Generally, yes. High initial income but quick plateau unless you are able to acquire equity somehow (typically sweat or buy-in).

 

[EctopicFetus]

I’m a new attending, I’m looking up salaries of other attendings who have been working like 15-20 years and they all get paid the same as me as a new grad. Do EM docs not get pay raises? Even with work experience? We’re salaried at an academic place. Am I destined to make the same salary for the rest of my life?

In academics get grants. But overall em pay is going down. I would be happy with no pay cut. Perhaps as you climb the academic ladder there is more money? Full professor etc?

 

[WilcoWorld]

Promotions in academics usually mean a modest pay raise, but the bigger benefit is having more clinical release time (which is effectively an hourly raise).

 

[southerndoc]

No, it's unlikely you'll get a raise. Matter of fact, you're likely to get a pay cut. Insurance companies are always looking for ways to cut your pay... hence the balance billing legislation that is now law. Board-certified emergency physicians use the same 9928x codes as family practice physicians working in the ER. They bill less on average. That brings down the median in-network rate, which will affect the out-of-network rates and force lower reimbursements. This coupled with new contracts at lower rates will lower the median in-network rate.

End result? More work for less pay. I've never been a "sky is falling" kind of guy with regard to emergency medicine, but there are a lot of things happening recently that have me very concerned and tempted to exit my career in emergency medicine (despite my love for it).

 

[trackrunner321]

CMGs could not care less how long you have been practicing (as long as you are not blatantly killing people) and will not reward you for it. The cheapest labor is the name of the game. Our only hope is avoiding huge pay cuts.

 

[emergentmd]

This is the same with almost every other field unless you become a partner/owner. The more you work, the harder you work, the more you make.

Your income is either attached to your RVUs or hours worked.

 

[sylvanthus]

Same with crit care, the guys 15 years my senior are making my salary. Course they have faaaaaarrrrr less debt, but still. Guess I reached the peak of my career? Next move? Save for nursing home? ugh. I feel the pain.

 

[EctopicFetus]

This is the same with almost every other field unless you become a partner/owner. The more you work, the harder you work, the more you make.

Your income is either attached to your RVUs or hours worked.

Do you mean every other field of medicine? That’s true. But if field means compared to law accounting or anything else in business then I Disagree. In medicine once you finish training you are an equal to others. In the other (non medical) fields there is a natural progression.

 

[emergentmd]

Do you mean every other field of medicine? That’s true. But if field means compared to law accounting or anything else in business then I Disagree. In medicine once you finish training you are an equal to others. In the other (non medical) fields there is a natural progression.

Of course I mean medicine. We are restricted by RVUs and billing codes. Unless you are an owner, no one knows if a 30 yr old just out of residency saw an MI vs a 50 yr old efficient doc.

Difference being an owner is the owner is skimming off the 30 yr old thus the increased income. The pot isn't any bigger and there is not an experience ICD10 code modifier.

 

[Fox800]

If you aren't getting a 3% raise yearly for inflation, you're getting a pay cut. Every. Single. Year.

I saw that there is legislation being pondered where midlevels at the VA would be making $200k/year + federal benefits (pension).

Why are we toiling for $300-400k year after 7 years of training and hundreds of thousands of student loan debt, when noctors can train online with 3% of the hours and make half of our pay again?

 

[WilcoWorld]

If you aren't getting a 3% raise yearly for inflation, you're getting a pay cut. Every. Single. Year.

I saw that there is legislation being pondered where midlevels at the VA would be making $200k/year + federal benefits (pension).

Why are we toiling for $300-400k year after 7 years of training and hundreds of thousands of student loan debt, when noctors can train online with 3% of the hours and make half of our pay again?

Because I like being a doctor?

 

[Fox800]

Because I like being a doctor?

Rhetorical question, Watson.

 

[Rekt]

Rhetorical question, Watson.

Also a really dumb answer.

 

[nimbus]

When the EM match collapses and there aren’t enough newly minted EM docs to meet the demand, compensation will increase. At lease that’s what happened in anesthesia around 1999-2002. The difference this time may be all the new med schools and med school graduates will result in EM residencies filling despite poor short term job prospects.

 

[southerndoc]

When the EM match collapses and there aren’t enough newly minted EM docs to meet the demand, compensation will increase. At lease that’s what happened in anesthesia around 1999-2002. The difference this time may be all the new med schools and med school graduates will result in EM residencies filling despite poor short term job prospects.

There's also a great deal of IMG's wanting spots too.

 

[thegenius]

You will make more / hour as time goes on though. Only if you are in a FFS (fee for service) model. This obviously won't happen in an hourly place. I work at a RVU only ER and I've been there for 7-8 years...and I continue to make more $$/hr, or the same $$/hr as I did the last year. I've never gone in reverse. I started off around 240/hr, then the next year 245/hr, then 250, 265, ...and at year 8 I got up to like 325.

The increase in hourly pay can be attributed to several things: 1) increased productivity and efficiency, 2) more pts coming in due to COVID, and 3) we got out from a CMG and are now under the hospital foundation.

 

[Tenk]

If you aren't getting a 3% raise yearly for inflation, you're getting a pay cut. Every. Single. Year.

I saw that there is legislation being pondered where midlevels at the VA would be making $200k/year + federal benefits (pension).

Why are we toiling for $300-400k year after 7 years of training and hundreds of thousands of student loan debt, when noctors can train online with 3% of the hours and make half of our pay again?

3%?

We going back to the 70s and 80s baby! Actually we are already there. They changed how they report inflation years ago. The actual number is much higher than 7.5% using the old standard.

 

[trackrunner321]

When the EM match collapses and there aren’t enough newly minted EM docs to meet the demand, compensation will increase. At lease that’s what happened in anesthesia around 1999-2002. The difference this time may be all the new med schools and med school graduates will result in EM residencies filling despite poor short term job prospects.

Anesthesia has rebounded, but they did not increase residency spots during their collapse. They also allowed spots to go unfilled and their market appropriately corrected itself. Unfortunately, EM has continued to increase residency spots through increased programs and increasing spots at existing programs. These new CMG programs will take any warm body and will not allow spots to go unfilled like anesthesia did. I fear that our market will not appropriately correct itself. We will see if there are any unfilled spots following the SOAP this year.

 

[EctopicFetus]

You will make more / hour as time goes on though. Only if you are in a FFS (fee for service) model. This obviously won't happen in an hourly place. I work at a RVU only ER and I've been there for 7-8 years...and I continue to make more $$/hr, or the same $$/hr as I did the last year. I've never gone in reverse. I started off around 240/hr, then the next year 245/hr, then 250, 265, ...and at year 8 I got up to like 325.

The increase in hourly pay can be attributed to several things: 1) increased productivity and efficiency, 2) more pts coming in due to COVID, and 3) we got out from a CMG and are now under the hospital foundation.

I think hospitals will more slowly adapt to the EM job market than CMGs but once they look up numbers the cuts will come there too. I do agree in this model you learn to be more efficient. The over arching em financial stress will impact us all.

 

[EctopicFetus]

Anesthesia has rebounded, but they did not increase residency spots during their collapse. They also allowed spots to go unfilled and their market appropriately corrected itself. Unfortunately, EM has continued to increase residency spots through increased programs and increasing spots at existing programs. These new CMG programs will take any warm body and will not allow spots to go unfilled like anesthesia did. I fear that our market will not appropriately correct itself. We will see if there are any unfilled spots following the SOAP this year.

There won’t be. Will take a few more years. But once med students hear from their friends that they couldn’t get jobs they will learn. for a select few it will be too late.

 

[Angry Birds]

I’m a new attending, I’m looking up salaries of other attendings who have been working like 15-20 years and they all get paid the same as me as a new grad. Do EM docs not get pay raises? Even with work experience? We’re salaried at an academic place. Am I destined to make the same salary for the rest of my life?

So, I got a big pay raise... But, this was due to being heavily underpaid in my first couple years as an attending. I did not know my own value.

You will make the salary you negotiate. Some places have no negotiation and everyone gets paid the exact same. Sometimes, however, even here they will make exceptions if you negotiate prior to hiring and if the need is there.

The way you get pay raises is by going to a different job and negotiating a higher pay there.

 

[Backpack234]

Most likely, you're making peak income on day one. Unless you work for a system like the VA that gives small % increases each year. Or if you work for a democratic group that give you a low salary as a buy in (or a low salary plus a buy in) until you're a partner. Or you could get a different job that pays differently. In my area, CMG sites pay around 190-200/hr. Hospital employee groups pay ~$220/hr plus some metric bonuses. And I believe the democratic group partners make >$300/hr. Pick your poison.

It's weird when you become an attending because suddenly there aren't really any more achievable professional goals. You made it to the top! Now....just stay there? Thing is, EM is tough. And unless you're in some unicorn gig, chances are you're gonna want out in the next 5, 10, or 20 years. Less likely that you'll keep doing this until you're 65. So you've gotta create some other goals for yourself.

Become your own financial advisor, learn how to achieve FI. No as activity intensive as medical training, but takes just as long and is a solid goal to have.

Become an investor. Some people do this full time as their whole career. As a doc you'll have enough cash flow and should have enough time to learn the basics of investing and see if that's something you like.

Become a landlord. Plenty of other docs build up entire second careers owning rental properties and eventually decide to leave medicine.

Work in urgent care. Work part time. Go to fellowship and become a pain medicine doc. Start a wound care practice. Do what that guy on facebook Mitch Li did and start your own telemedicine primary care thing.

Or realize that even in an entire career in emergency medicine, you still won't be perfect. It's a constant struggle to improve. So maybe the goal is just to be the best ER doc you can be, even if it's not measurable in terms of degrees and promotions. And even if it means you never make more money that you did on day 1.

 

[CliveStaples]

I’m a new attending, I’m looking up salaries of other attendings who have been working like 15-20 years and they all get paid the same as me as a new grad. Do EM docs not get pay raises? Even with work experience? We’re salaried at an academic place. Am I destined to make the same salary for the rest of my life?

To address your specific question, it depends on your academic institution and what they've done historically. At mine, while raises have not occurred every year, there have actually been steady raises that occur every few years historically at my ivory tower's EM department. In addition, there's the promotion pathway which confers a pay bump, but I wouldn't call it "game changing" and there are certainly faculty that decide the juice isn't worth the squeeze, so to speak, and remain at a rank of assistant professor for their careers.

As accurately depicted above, the game in academics is usually to figure out what you like to do and what is worth your energy to get clinical release time. For many academicians, the reason they pursue that career is because they have better wellness and career longevity working 90 clinical hours a month and spending 30 hours doing research, sitting on hospital committees, being in a residency program leadership position, etc. than working clinically for 120 hours a month. Likewise, it's possibly to simply leverage the hours you're getting for academic purposes but to continue to work closer to a full time clinical load, which is where academicians generally get paid more than their publicly listed salaries would indicate.

 

[sylvanthus]

There won’t be. Will take a few more years. But once med students hear from their friends that they couldn’t get jobs they will learn. for a select few it will be too late.

Have you not seen what med students post? They wont learn. “i cant see myself doing snything else” “I love EM!” blah blah blah.

They get advice on here all the time and refuse to listen. Look at the guy who was already an attending and refused to listen about going back to do EM.

They wont listen, the spots will still fill. Everyone is a special snowflake and will find a great job or is totally cool living in kansas so they can practice EM.

 

[bravotwozero]

Have you not seen what med students post? They wont learn. “i cant see myself doing snything else” “I love EM!” blah blah blah.

They get advice on here all the time and refuse to listen. Look at the guy who was already an attending and refused to listen about going back to do EM.

They wont listen, the spots will still fill. Everyone is a special snowflake and will find a great job or is totally cool living in kansas so they can practice EM.

While it certainly seems that way online, i've been in academics for the past 2 years, and met only 1 med student that was applying EM, and she was there as a sub I. Literally everyone else was applying to a different field.

All bets are off with FMGs though. That being said, a lot of those applicants need visa sponsorship, and many programs don't offer that. That is something resource intensive, so remains to be seen how many EM programs will decide they are willing to pony up extra dough to sponsor these residents. Time will tell.

 

[southerndoc]

There should be an interesting thing happen in the next few years with emergency medicine. CMS, and insurers will follow, will implement a rule that in order to bill 100% for services starting next year, the substantive portion of medical care must be provided by the physician and not by the NP/PA. If the majority of care is provided by the NP/PA, then they can only bill for 85% of the charge.

This is going to cause CMG's to lose money, and I'm not sure what will happen with it. Will it cause less NP/PA's to be utilized, or will they just cut their losses and employ them more thinking the more patients they see, the more they can make up for the 15% lost revenue. I'm sure NP/PA's will advocate strongly for this to not take effect.

 

[sylvanthus]

While it certainly seems that way online, i've been in academics for the past 2 years, and met only 1 med student that was applying EM, and she was there as a sub I. Literally everyone else was applying to a different field.

All bets are off with FMGs though. That being said, a lot of those applicants need visa sponsorship, and many programs don't offer that. That is something resource intensive, so remains to be seen how many EM programs will decide they are willing to pony up extra dough to sponsor these residents. Time will tell.

Ya I dont know man, I have med students through the ICU frequently and have tried to steer those going for EM onto another path. Hasnt worked yet. While its all anecdotal I highly doubt any significant number of positions are going to go unfilled.

Hell even if some go unfilled the sheer number of programs and spots opening up is ridiculous. It would take a significant number of spots unfilled to make any difference whatsoever.

 

[sylvanthus]

While it certainly seems that way online, i've been in academics for the past 2 years, and met only 1 med student that was applying EM, and she was there as a sub I. Literally everyone else was applying to a different field.

All bets are off with FMGs though. That being said, a lot of those applicants need visa sponsorship, and many programs don't offer that. That is something resource intensive, so remains to be seen how many EM programs will decide they are willing to pony up extra dough to sponsor these residents. Time will tell.

around.

It would take 500 unfilled positions to get us back to the number of residents just a few years ago. I just cant see that happening.

 

[EctopicFetus]

There should be an interesting thing happen in the next few years with emergency medicine. CMS, and insurers will follow, will implement a rule that in order to bill 100% for services starting next year, the substantive portion of medical care must be provided by the physician and not by the NP/PA. If the majority of care is provided by the NP/PA, then they can only bill for 85% of the charge.

This is going to cause CMG's to lose money, and I'm not sure what will happen with it. Will it cause less NP/PA's to be utilized, or will they just cut their losses and employ them more thinking the more patients they see, the more they can make up for the 15% lost revenue. I'm sure NP/PA's will advocate strongly for this to not take effect.

Meh. Beyond substantive soon it will be over 50% of the time. This will be Medicare only. As it is now if a MLP sees a patient they pay 85%. outside of Alabama i haven’t heard of commercial insurance following. Will be interesting but it’s not like a doc makes 15% of an MLP (yet) so still better to have an MLP and cut their pay or even easier cut the docs pay to keep profit steady. Be sure and I know you know this. The contract holders will protect their profit. Doc pay easiest to cut.

 

[Groove]

There should be an interesting thing happen in the next few years with emergency medicine. CMS, and insurers will follow, will implement a rule that in order to bill 100% for services starting next year, the substantive portion of medical care must be provided by the physician and not by the NP/PA. If the majority of care is provided by the NP/PA, then they can only bill for 85% of the charge.

This is going to cause CMG's to lose money, and I'm not sure what will happen with it. Will it cause less NP/PA's to be utilized, or will they just cut their losses and employ them more thinking the more patients they see, the more they can make up for the 15% lost revenue. I'm sure NP/PA's will advocate strongly for this to not take effect.

How are they going to tell that the physician provided the majority of care? As it stands, the common practice is for the CMG to bill under the physicians NPI which is why we all get forced to sign the APC charts and APC MIPS fallouts show up under us. I've had to do this at almost every CMG shop I've ever worked except one.

 

[EctopicFetus]

How are they going to tell that the physician provided the majority of care? As it stands, the common practice is for the CMG to bill under the physicians NPI which is why we all get forced to sign the APC charts and APC MIPS fallouts show up under us. I've had to do this at almost every CMG shop I've ever worked except one.

You are gonna document that. Commit fraud and you are screwed. How are you gonna keep track of time? Makes sense to have all 65+ seen by docs only.

 

[RustedFox]

How are they going to tell that the physician provided the majority of care? As it stands, the common practice is for the CMG to bill under the physicians NPI which is why we all get forced to sign the APC charts and APC MIPS fallouts show up under us. I've had to do this at almost every CMG shop I've ever worked except one.

You are gonna document that. Commit fraud and you are screwed. How are you gonna keep track of time? Makes sense to have all 65+ seen by docs only.

My CMG gig at present has several attestations; one for "I reviewed the chart and was available", one for "I saw the patient", and one for "I assumed care of this patient from the MLP."

 

[Apollyon]

My CMG gig at present has several attestations; one for "I reviewed the chart and was available", one for "I saw the patient", and one for "I assumed care of this patient from the MLP."

How often is that third one "I saved a pt from an assassin"?

 

[RustedFox]

How often is that third one "I saved a pt from an assassin"?

It's not as often as it was at the old shop, as the MLPs at new gig actually listen to what is told to them. This is in stark contrast to old shop, where the MLPs had an oppositional-defiant attitude because they went between 2 hospitals with very, very different levels of physician oversight.

You might remember me complaining about them acting like the children of divorced parents, and saying things similar to "mom doesn't make me do this at her house".

"Well, this is dad's house, and here we do things the right way."

 

[TrailRun]

You are gonna document that. Commit fraud and you are screwed. How are you gonna keep track of time? Makes sense to have all 65+ seen by docs only.

Our phrase is "I provided a substantive portion of the care." In fairness if my license is on the line then I should be reimbursed for that. I guess the 'substantive portion' is deciding and signing off on the plan of care, as I do staff all the midlevel patients.

 

[southerndoc]

Our phrase is "I provided a substantive portion of the care." In fairness if my license is on the line then I should be reimbursed for that. I guess the 'substantive portion' is deciding and signing off on the plan of care, as I do staff all the midlevel patients.

That doesn't cut it. You have to document you spent more time than the PA/NP either during their entire ER stay. If they were there for 2 hours, you were providing more care than the NP/PA for at least 61 minutes. How are you going to prove that?

It's really going to affect the ability to justify the cost of NP/PA's.

 

[Groove]

You are gonna document that. Commit fraud and you are screwed. How are you gonna keep track of time? Makes sense to have all 65+ seen by docs only.

Yeah, but as it stands, there aren't enough physicians to physically see all the pt's + the ones that the APC sees. The CMG bills under my NPI regardless of whether I place an attestation or not. I don't think that's just a TH thing...as I had it happen with Apollo and Schumacher also. So, that gets you what?...15% more revenue from the APC cases. Let's say CMS complicates that issue and demands more stringent documentation and/or attestations to imply "majority of care" by the MD. Nobody is going to want to document it if they didn't perform it. Which leads to no CMG wants to hire another FTE MD that they have to pay 2-3x the rate of the APC simply to generate 15% more revenue from (typically fast track) cases. I just don't get how this makes any progress on undermining APCs in the ED.

For those of you having to play attestations that you have reviewed APC charts on cases where you didn't see them and weren't consulted. I think that makes you potentially complicit to any malpractice because the lawyer can always argue that you reviewed the case and it was your job to determine if standard of care was maintained. If not, why didn't you call the pt back, etc..? I find it far easier to justify simply signing the case because it is a requirement of my employer than placing an attestation approving their medical management. If it's a really hairy case, I'll either not sign it or provide a statement that I was available but not consulted and can't make a determination on appropriateness of care without doing my own HPI/PE and that the APC practiced independently during that encounter, etc..

 

[Groove]

Many of my shifts, I'm seeing 2.5PPH easily. If I had to see all the APC pt's, that would push me to 3.5PPH or higher. I don't see how it's physically possible and hiring more MDs to handle the job just ends up hurting the CMG bottom line. If I were them, I'd simply hire more APCs and eat the 15% at $70/hr versus hiring a doc for $250/hr. I can get 3.5 APCs for the same cost who can probably see almost 6-7PPH and I'm only losing 15% on each chart.

 

[Groove]

As for salaries, they are simply going down and there's very little we can do about it. We get a quarterly revenue bonus where I'm at and I was calculating out my hourly for the past quarter and it came to about ~235/hr which is less than I've ever made in my region (Used to average about ~265). One of my new grad colleagues was grumbling about it and came in at ~228 or so and I just told them..."Well, what are you gonna do? What CAN you do? Where are you going to work? There's 10 new grads waiting to take your job who would be grateful for 228. Hell, they might do it for 175 or even less if they've been trying to find a job very long. Nowhere else in the city is going to pay you much more. Gone are the days of scalping shifts for $600/hr. It's time to get used to the pay dropping to match the supply. This is what happens when (CMG sponsored) residency programs run amok and start saturating a job market. Market forces are simply performing as expected....nothing more."

I can see the CMG execs standing back, playing out the scene from Dune (2021) where Thufir Hawat is talking to Duke Atreides after the meeting with Stilgar:

"Our plan bears fruit!....."

 

[RustedFox]

As for salaries, they are simply going down and there's very little we can do about it. We get a quarterly revenue bonus where I'm at and I was calculating out my hourly for the past quarter and it came to about ~235/hr which is less than I've ever made in my region (Used to average about ~265). One of my new grad colleagues was grumbling about it and came in at ~228 or so and I just told them..."Well, what are you gonna do? What CAN you do? Where are you going to work? There's 10 new grads waiting to take your job who would be grateful for 228. Hell, they might do it for 175 or even less if they've been trying to find a job very long. Nowhere else in the city is going to pay you much more. Gone are the days of scalping shifts for $600/hr. It's time to get used to the pay dropping to match the supply. This is what happens when (CMG sponsored) residency programs run amok and start saturating a job market. Market forces are simply performing as expected....nothing more."

I can see the CMG execs standing back, playing out the scene from Dune (2021) where Thufir Hawat is talking to Duke Atreides after the meeting with Stilgar:

"Our plan bears fruit!....."

Instead, I see the 1984 DUNE scene where Baron Harkkonnen tells Raban to "squeeze, SQUEEEEZZE!"

 

[chillaxbro]

As for salaries, they are simply going down and there's very little we can do about it. We get a quarterly revenue bonus where I'm at and I was calculating out my hourly for the past quarter and it came to about ~235/hr which is less than I've ever made in my region (Used to average about ~265). One of my new grad colleagues was grumbling about it and came in at ~228 or so and I just told them..."Well, what are you gonna do? What CAN you do? Where are you going to work? There's 10 new grads waiting to take your job who would be grateful for 228. Hell, they might do it for 175 or even less if they've been trying to find a job very long. Nowhere else in the city is going to pay you much more. Gone are the days of scalping shifts for $600/hr. It's time to get used to the pay dropping to match the supply. This is what happens when (CMG sponsored) residency programs run amok and start saturating a job market. Market forces are simply performing as expected....nothing more."

I can see the CMG execs standing back, playing out the scene from Dune (2021) where Thufir Hawat is talking to Duke Atreides after the meeting with Stilgar:

"Our plan bears fruit!....."

Jokes on me, I should have just done family med

 

[RustedFox]

Jokes on me, I should have just done family med

He said, like so many of us.

 

[dadaddadaBATMAN]

That doesn't cut it. You have to document you spent more time than the PA/NP either during their entire ER stay. If they were there for 2 hours, you were providing more care than the NP/PA for at least 61 minutes. How are you going to prove that?

It's really going to affect the ability to justify the cost of NP/PA's.

Could be wrong, but thought for 2022 the standard is more than half for one component, history, mdm, etc.

Think the more than half total visit kicks in in 2023.

At that point they might as well fire a few midlevels and hire a scribe, because that will be the only function a shared visit helps with.

 

[Janders]

That doesn't cut it. You have to document you spent more time than the PA/NP either during their entire ER stay. If they were there for 2 hours, you were providing more care than the NP/PA for at least 61 minutes. How are you going to prove that?

It's really going to affect the ability to justify the cost of NP/PA's.

Not quite yet my friend.

2022 rules—
Substantive Portion Definition in 2022 for E/M Levels
“For 2022, the substantive portion will be defined as one of the following:
• One of the three key components: history, exam, or MDM;
or
• More than half of the total time spent performing the shared visit.”

So either you claim more than half the time (certainly possible if you’re using the PA as a procedure-helper, chart scriber, etc… but still not the most common approach) OR you claim the substance portion of either Hx, PE OR MDM.

What is the substantive portion of one of those?
“the billing practitioner must perform the level of history/PE/MDM required to select the visit level billing”

So, the easy one to claim is MDM… the PA does the hx and PE, you discuss the case together and you perform the “substantive” MDM in the case (in real time).

Easy peasy if you at least have patients presented to you in real time (I think the minimum standard).

NOW, in 2023 the proposed rules ARE about 1/2 the time of the visit, which is going to be rather different.

And of course critical care billing is a different animal.

 

[turkeyjerky]

And of course critical care billing is a different animal.

Anyone else get triggered when they see a midlevel bill critical care?

 

[EctopicFetus]

That doesn't cut it. You have to document you spent more time than the PA/NP either during their entire ER stay. If they were there for 2 hours, you were providing more care than the NP/PA for at least 61 minutes. How are you going to prove that?

It's really going to affect the ability to justify the cost of NP/PA's.

This change is coming. For this year the “substantive portion” bit is good enough. We are using that now. We will simply push the 65 and up to docs only which we have been doing for some time anyhow.

 

[EctopicFetus]

Many of my shifts, I'm seeing 2.5PPH easily. If I had to see all the APC pt's, that would push me to 3.5PPH or higher. I don't see how it's physically possible and hiring more MDs to handle the job just ends up hurting the CMG bottom line. If I were them, I'd simply hire more APCs and eat the 15% at $70/hr versus hiring a doc for $250/hr. I can get 3.5 APCs for the same cost who can probably see almost 6-7PPH and I'm only losing 15% on each chart.

Remember this is only Medicare. Push all the 65+ to docs and keep everything else as is. It’s not complicated. Insurers may follow suit but until they do why change in a major way. Wait it out until there are 10k too many of us and see our rates approach that of mlps who will leave the Ed to do derm or do Botox.

 

[Siggy]

Anyone else get triggered when they see a midlevel bill critical care?

It's always fun when I get a call to admit a patient to the ICU from a PLP. Especially since half the time they know nothing about the patient.

That said, this change is amazing for generating inpatient 99292s.

Day team bills, say, 35 minutes (I just build off of the MD/DO's attestation).

Night NP: Additional 20 minutes for a total of 55.
Night MD/DO: Attests to additional 25 minutes for a total of 80 minutes.

Much easier than needing one or the other do the whole 40 minutes for a -92. The only key is to make sure that the MD/DO bills more time than the PLP.

Edit:

Another nice change with this is after midnight care. Prior to this year the first person billing a 99291 had to reach 30 minutes by themselves. So if I do something minor at 3am (say, 10 minutes of CCT), then that time was unable to be billed. Now that time can be added to additional time later in the day (say, 10 minutes at 3 am, day team does another 35 minutes, now the night team is starting at 45 minutes in order to reach a -92.