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I'm a senior EM resident deciding between a few jobs. I was offered a job from a CMG that pays their docs 100% RVU. What are the pros/cons of such a job?
 

Birdstrike

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Pros-If you work hard and see a lot of patients you'll make lots more money than the slow ones.

Cons-If you're slow you take a financial hit. Also, can prompt cherry picking charts that have a higher RVU/pain ratio.
 

sb247

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At a 100% RVU job you'll be very subject to the impact of people you don't employ. Nurses don't get your orders completed and the turnover rate slows? You lose money. Admitting takes too long? You lose money. Janitorial doesn't clean the room fast enough? You lose money

You can potentially make more but you need to consider the risk
 
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Vandalia

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The obvious answer is that they are offering 100% RVU because they feel it will it will be financially better for them. That should raise questions by you.

It depends a lot on the practice details. If it is low volume, it means you will be sitting their twiddling your thumbs while the ED is empty and you are not getting paid.

If it is a busy place with several physicians, it can motivate bad behavior - cherry picking, avoiding the non-RVU activities, etc., etc.

It also depends a lot on the rate per RVU. But I would always come pack to my first sentence.
 
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filhodeinferno

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I'm a senior EM resident deciding between a few jobs. I was offered a job from a CMG that pays their docs 100% RVU. What are the pros/cons of such a job?
I'm a resident as well, so I don't know from experience, but it seems like a job like that would stress me out. I'd always be worrying about volumes, how fast the nursing and support staff are working, and ways that I can do extra stuff to get paid more. An RVU bonus would be nice, but 100% RVA would give me anxiety.
 

Arcan57

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The obvious answer is that they are offering 100% RVU because they feel it will it will be financially better for them. That should raise questions by you.

It depends a lot on the practice details. If it is low volume, it means you will be sitting their twiddling your thumbs while the ED is empty and you are not getting paid.

If it is a busy place with several physicians, it can motivate bad behavior - cherry picking, avoiding the non-RVU activities, etc., etc.

It also depends a lot on the rate per RVU. But I would always come pack to my first sentence.
That's a lot of info and assumptions packed into a pretty concise paragraph. Let's break it down Sunday Night Football style:

1) CMGs operate under the same model that casinos use with poker and bookies use with betting. They're going to get their cut. The only way they lose is if they screw up setting the system(which they don't do) or the playing field changes (ie. offering a highball RVU multiplier when pt mix ends up sucking or offering a huge $/hr when volume craters due to inadequate nursing staff or unexpected competition). Pay with the RVU model tracks better with volume fluctuations but it's possible to hide huge profits in any model. CMGs offer a particular compensation model largely depending on how it effects their ability to recruit with a tendency towards flat hourly rate if possible.

2. You should expect the CMG to cough up some site average or target that can be checked with the docs currently working there. Try and find out what the newest doc(s) make(s) to see if the average is being inflated by people that only work high RVU shifts.

3. Sort of agree with the slow and busy statements but there's a lot of nuance that is missing. If you're doing RVU only (or RVU + floor with a floor so low it's essentially an RVU shop), then you need to worry about two things. Are there docs that cherry pick cases so as to mess up your case mix when you work with them? And do the shifts I work have a different volume/acuity then the group as a whole? The first is something that should be identified while interviewing, the second is something that nocturnists are keenly aware of but may slip by some docs with other specialized schedules. For example if you do a bunch of swing shifts so you can get the kids off to school, it's going to matter quite a bit whether the department is always full of holds from noon to 6p. If you work evenings because that's the busiest doc shift, do you end up losing out on midlevel RVUs because there's a doc in fast-track signing those charts for 2/3 of your shift?

4. Pertinent questions in an RVU only model - how much per hour does the lowest performer in the group make, how much do the night docs make, and is there a different multiplier for night/weekend shifts?

5. While it's definitely possible to rig an RVU only model to screw certain classes of practitioners, I would say that I've lost far more income and been far more frustrated working in the flat hourly model when I'm picking up 3/4 of the patients making the same as the doc sitting on their ass surfing the web.
 

Vandalia

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To get more specific, I really wouldn't take a 100% RVU job right out of residency.

(However, again, it is all about the details/options. If your spouse says they will divorce you if you do not live in town X, and the other group in town offers a salary of $50/week, then maybe.)

As a new graduate, you will not be productive - and you should not be productive. That is why new graduates get a lower salary than a veteran. However a salary base removes the immediate preoccupation with productivity and gives you the buffer to really think about what you are doing and ask questions. The other problem is that if everyone else is on 100% RVU, they are not going to spend the time to answer those questions. Plus - and this is important - they are going to be a whole lot better at playing the RVU game and leaving you stuck with the "bad" cases.

In the blink of an eye, you will wake up one morning and realize you have been doing this for 20 years. I realize it is incredibly tempting when you hear the relatively big numbers thrown around for your first real job. However, resist that temptation and pick the job that will be best for you in the long term. Even though you are licensed, have privileges, and will soon be board certified, there is still a lot of stuff you need to learn. Pick the job that will let you complete your development. Then, after a year or two, you will be ready to chase the more lucrative positions. Think of this as the EM fellowship. Worrying too soon about RVUs can result in bad decisions, and a bad reputation that can hurt you for many years to come. It is still a small world. If you are applying for a job, I bet I know someone who knows someone who knows you. If I call a surgeon I used to know in the AF, and ask about you, and the first words out of their mouth is "that idiot", ... it is not good.

------------------

Arcan47's post popped up while I was typing the above. The distinction is between a 100% RVU model for a new residency grad, and the 100% RVU model in general.

If the standard contract is base+incentive, and then they offer you as a new graduate 100% RVU, then that 90's song "Things that make you go, hmmm" should pop into your mind. As a partner in a "democratic" practice, I guess you could say I am on 100% RVU in reality. As above, I don't have a problem with that model for an experienced EM physician who knows the situation and knows the questions to ask, for a newbie, ... beware.

An analogy: I have no problem negotiating with a car dealership for a new car. However, I would not leave my son alone in that situation at 18 when he buys his first (used) car. That is definitely something he needs to learn eventually and handle on his own, but not the first time on his own at that age.

From my previous posts, I don't believe in throwing people into the fire at the first opportunity. Be it an intern in July with an iffy consult to a difficult consultant, or a new grad dealing with a tricky job. But that is me.
 
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Angry Birds

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I'm a resident as well, so I don't know from experience, but it seems like a job like that would stress me out. I'd always be worrying about volumes, how fast the nursing and support staff are working, and ways that I can do extra stuff to get paid more. An RVU bonus would be nice, but 100% RVA would give me anxiety.
I couldn't agree more with this post.

It's not just about who is an efficient and hard-working doc. It's also about documentation and billing, something that not many residencies teach adequately (I know mine certainly didn't). Coming straight out of residency, it is likely that you will be on the low end of this RVU pay scale. The people I've seen who tend to be on the high end are very senior EM physicians who have taken lots of courses on billing & coding, etc.

But, the real question is: why would you want that stress? Isn't our job stressful enough? Now you want to worry about taking home enough to eat? F that.

I briefly talked to a place that was pure RVU based, and when I saw their averages, I realized that the average was very similar to the average pay at other hospitals. Why would I take on all that extra stress when I can get paid the same elsewhere without that stress? I'm not assuming that 1 year out of residency I'm already on the high end of charting.

Speaking of, I gotta be honest: I'd rather pass on RVU places because I hate having to worry about how to pad my charts. I know I'll get heat for that, but really I could care less about that. Because I don't want that extra worry, I avoid places based on RVU models and live in ignorant bliss as to how my charts stack up against others. Just one less thing for me to worry about. Shrug. To each their own.
 

emergentmd

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I'm a senior EM resident deciding between a few jobs. I was offered a job from a CMG that pays their docs 100% RVU. What are the pros/cons of such a job?
If it was an independent group and you will be a partner soon. YES

Otherwise, NO. BIG NO. How do you even trust that they are paying you 100% RVU if you can't see the books? As a partner, you are allowed to see the books, see what others are making relative to how much RVU they are producing.
 
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My residency certainly doesn't emphasize... what are those things? RVUs?

Similar question - what kind of "floor" in "floor plus rvu" model would you consider?

Also, how does the RVU multiplier work?

Thanks in advance...
 

The Buff

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Just to offer a counterpoint to this thread...I took a 100% RVU job straight out of residency and did just fine. There are pros and cons to any system so you have to be aware of those.

Pros--
--If you see many complicated pts and/or do more procedures, you get paid more.
--If you get killed on a shift, it hurts less because you make more. Mom brings in her 4 kids with sniffles? You make more.
--That other doc you working with not keeping up and wants you to help out? You make more (and he makes less).
--There is a certain satisfaction to literally eating what you kill. It always tastes better if you make it yourself, right?

Cons--
--Slow shifts: being at work and not making money is not fun.
--Potential for cherry picking, see below.
--Your paycheck fluctuates from month to month so it can be less predictable what you will bring home.
--There is the stress factor, but I think this goes away once you get used to it.

Things to consider--
--I think the best places to work for pure RVUs are ones that always have a bit of pressure from the waiting room. This means you can work as fast as you can and not worry about idling not making money.
--The cherry picking: most places that are set up well know this can be a problem and have defenses against it. There is usually not a "pick the next chart from the rack" system. Instead shops will use a strict every other pt thing, or a pod system, or the like.
--How much do you make per RVU? They will never pay you 100% of the RVUs you take in unless you own the contract or something. Most places will tell you this percentage up front.
--A good place should give you a break down of where your RVUs are coming from. One place I worked showed every pt seen in the month and how many RVUs you got for that pt and why. Less helpful is just a monthly total.
 
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Old_Mil

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Unless you get to wear two hats - CEO and Pit Doc - there is never a good reason to take a straight RVU job.

At a 100% RVU job you'll be very subject to the impact of people you don't employ. Nurses don't get your orders completed and the turnover rate slows? You lose money. Admitting takes too long? You lose money. Janitorial doesn't clean the room fast enough? You lose money
This is why. You're a very highly educated assembly line employee. Don't put yourself in a position where your paycheck can take a hit because of mistakes made at a higher pay grade.
 
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Thanks for the replies! I will likely have to take this job as I'm restricted geography. What kind of things should I put in my contract to try and protect myself?
 

Dakota

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I work at two different sites. My primary job is technically base plus an RVU bonus, but the floor is so low it is effectively all production. The second site I work is a much smaller ED that is a straight hourly.

I was initially nervous about production based pay, as a resident I had no idea my average RVUS per patient and RVUS per hour. However, I have discovered I like the production based pay much better for reasons others have mentioned. When I am getting killed at my primary job I can leave a shift exhausted but feel well paid. When I get killed at the smaller ER I just leave the shift exhausted and feel like the pay per hour wasn't worth it.

I used to get antsy with the production based job when the waiting room was empty, but I have learned to enjoy the (very few) lower stress days.

See if you can get information with a breakdown of patients per hour, RVUS per patient, and RVUS per hour averaged over a pay period for each provider. Having access to that made me more comfortable by letting me see the range of salaries, and how people were getting to their RVU per hour figure (lots of pts per hour with low RVUS per patient, average pph and average RVUs per pt, etc).

Good luck.
 
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EctopicFetus

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Thanks for the replies! I will likely have to take this job as I'm restricted geography. What kind of things should I put in my contract to try and protect myself?
You can try but I doubt a CMG is gonna let you do much in the contract. Biggest thing to protect yourself is your out and having them cover your tail. I too would advise against this but if you have to then you have to. You may notice that some docs work more of a certain shift due to higher RVUs. Remember the RVU system is incredibly flawed. I could see maybe 6-10 old stable chest pain patients per hour without batting an eye. That admission is a fair number of RVUs. Depending on patient allocation you could end up doing long painful workups like abdominal pain, weak and dizzy gomers and make not nearly as much for much harder and more painful work.
 

Birdstrike

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Biggest thing to protect yourself is your out and having them cover your tail.
Another thing do to protect yourself is to not buy a house the first year at any new job. Rent, rent, rent. That gives you the power to say,

"See ya...wouldn't wanna be ya..."

If you stretch to buy some huge house, and you're attached, then they've got you by the gonads (take note of the very PC and gender neutral use of "gonads" as opposed to some other Cro-Magnon-like terms).

:)

If you're not mobile, or financially overextended, EM can really hurt, hurt, hurt.
 
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GeneralVeers

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You can always do locums and increase your pay 2X if you decide to leave your primary job. No one is stuck in one place any longer even if you buy a house. Locums is a good bridge even if for 6 months to a year while you find a new job.
 
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Old_Mil

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What kind of things should I put in my contract to try and protect myself?
Well, for starters...

1. Who is your contract with? Is it with a single purpose LLC that exists only to contract with the hospital and the docs for that particular site? Does that LLC self insure against malpractice? If so, you're wandering around like the emperor with no clothes. That LLC's assets, which essentially are your only insurance, only consist of 30 day receivables. If something really bad happens, a well timed bankruptcy leaves you hung out to dry.

1a. Make sure your malpractice clause is ironclad, stating what sort of insurance you will be provided, if tail is provided, who pays for that tail, and the limits of the policy.

2. How long is your notification period to quit? A lot of contracts will have something like a 30 day notice without cause, or a 0 day notice with cause and then turn around and keep you on the hook for 4-6 months if you want to quit. That's to make their life easier so they aren't put into an immediate staffing crunch. However, you should accept no more than a 30 day out clause if you want to quit. That way if something becomes intolerable, you can hit the road.

3. Don't spend any signing bonus you may get. See #2 above. You want to be able to give back whatever you owe if you need or want to leave.

4. CME: probably not an issue for a 1099 job with a CMG that gives you none, but some contracts will try and get you to pay the hospital back for any CME that you do within one year of your last shift.
 

RustedFox

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Off-topic, but I'm happy to see Old_Mil back here again. If I recall correctly, he and I were on the residency interview trail together.


Dude... I get that you're going to Soviet Canuckistan to work. You recently posted something like "thank christ that I'm leaving this broken wasteland behind".

Expound, man. We want to hear.
 

Old_Mil

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Off-topic, but I'm happy to see Old_Mil back here again. If I recall correctly, he and I were on the residency interview trail together
Yep...good times.

Dude... I get that you're going to Soviet Canuckistan to work. You recently posted something like "thank christ that I'm leaving this broken wasteland behind".

Expound, man. We want to hear.
I finally realized Obi Wan was right.



Just in time for ICD-10, the new WV court ruling, and Utah's possible massive license renewal fee too.

Besides, spending your retirement working at Tim Horton's beats the hell out of being a Wal-Mart greeter. Although I may have to get one of those furry Russian army hats to keep from freezing to death in January.
 

Birdstrike

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I believe this is what he is referring too.... http://epmonthly.com/article/you-re-suing-me-for-what/
This is not news and wasn't news, as far as I was concerned, when this ruling came down. There's been many lawsuits like this, in many states and many specialties. You should operate under the premise that you can get sued for any stupid, boneheaded, baseless and frivolous reason at any time. That doesn't mean they're going to win, and neither does this ruling. But when I saw this ruling, I yawned, frankly.

Practice good medicine, cover your bases, get good insurance, and when (not if) you're hit with some frivolous suit: lawyer up. It doesn't have to be life altering, earth shattering, or send you into a downward emotional spiral. It's part of the deal.

Did you know lawyers sue each other all the time? It's called legal malpractice. They do this to each other all the time. Yeah. It's no big deal to them. Lol
 
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Brigade4Radiant

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I used to think RVU was the best model. I wanted to work hard, get paid hard! That's what I thought atleast until I became an Attending working for ApolloMD. The thing about RVU's is that no one doctor can see patients alone. Get that through your head and be aware of the shop that you are working at. What I mean by that is that you have to have nurses or techs administer your orders. Take my shop for example, to get to the average pay of like 220 (Really 235 but minus 15 dollar scribe charge) you have to see 2.3 pts an hour to get the average I saw 1.9 pts per hour the average is like 2.1 pts per hour. I made 15 dollars less than the average despite have double the amount of critical care time because the charts assigned to me was lower than average.

You also have to factor in boarding pts, nursing shortages (meaning you can't see that many patients out front). Also if you work on a day where there is a blizzard and no one shows but you have to come in and you are stranded at the hospital you get no money. You are also at the mercy of midlevels who like to sign patients over to certain docs, seeing sicker patients or patients who require more time (nose bleeds) gets you rewarded with less pay.

Also even if you bust your tail you will only be making 10 bucks more than average and that's assuming you have more PA charts than average as well.
 

GeneralVeers

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I would not. I want a guaranteed hourly rate for when I show up. If it's not busy, I am still a warm body that they are required to have there. It's my time, and if I see 0 patients, I still want to be paid. My current setup is about 2/3 salary, 1/3 RVU which I think is decent. It's nice to know that I'm making $200+/hour surfing the internet when it's not busy.
 
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GonnaBeADoc2222

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I would not. I want a guaranteed hourly rate for when I show up. If it's not busy, I am still a warm body that they are required to have there. It's my time, and if I see 0 patients, I still want to be paid. My current setup is about 2/3 salary, 1/3 RVU which I think is decent. It's nice to know that I'm making $200+/hour surfing the internet when it's not busy.
Exactly.

Would be very cautious as a new grad taking this kind of job. I'm a 1st year attending and I'd be scared to. Not only are you just not that great at coding and documenting for the purposes of billing, but can be easily bullied into being the one to take the low volume shifts. If I took this type of job, I'd be very careful to have specific verbiage in my contract about the types of shifts I would be working.

If I'm on the overnight (I hate overnights already as it is) and volume dies at 3am, I want to be paid. I/you (in most cases) are a BC/BE Emergency Physician keeping their ED open and are extremely valuable. You should be paid for your professional time.
 

Brigade4Radiant

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Exactly.

Would be very cautious as a new grad taking this kind of job. I'm a 1st year attending and I'd be scared to. Not only are you just not that great at coding and documenting for the purposes of billing, but can be easily bullied into being the one to take the low volume shifts. If I took this type of job, I'd be very careful to have specific verbiage in my contract about the types of shifts I would be working.

If I'm on the overnight (I hate overnights already as it is) and volume dies at 3am, I want to be paid. I/you (in most cases) are a BC/BE Emergency Physician keeping their ED open and are extremely valuable. You should be paid for your professional time.
Yeah true my contract changed but I had to stay with the group due to a signing bonus.
 

gamerEMdoc

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Yeah, I want to rejoice when I clear the board on a night shift, or have a slow night and can get some admin stuff done. I don't want to fear clearing the place out because no more money would be coming in. Its just a mental thing. On the other hand, it obviously does make it easier when you are getting killed. If you are would consider taking one of these jobs out of residency, I'd definitely take a coding course, and I'd look and make sure to find out who codes the charts. I can tell you independent coding groups are going to be much more aggressive about coding charts higher (getting you more rvu's) than a hospital coder because they are typically trained just in ED billing/coding.
 

emergentmd

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I would not take a 100% RVU. CMGs hides their books so this adds another layer of confusion for the docs.

When we were a private SDG, we started with 100% RVUs but then you start getting discontent with docs in poor payer mix, docs fighting for charts, docs chart watching, docs not picking up Low RVU charts.

Its a bad practice that pits docs against docs.
 

EctopicFetus

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Yeah, I want to rejoice when I clear the board on a night shift, or have a slow night and can get some admin stuff done. I don't want to fear clearing the place out because no more money would be coming in. Its just a mental thing. On the other hand, it obviously does make it easier when you are getting killed. If you are would consider taking one of these jobs out of residency, I'd definitely take a coding course, and I'd look and make sure to find out who codes the charts. I can tell you independent coding groups are going to be much more aggressive about coding charts higher (getting you more rvu's) than a hospital coder because they are typically trained just in ED billing/coding.
The hospital based coders are usually terrible at their job. I would never take an RVU job if that was the case. I would prefer someone who is an expert at EM coding, not someone who doesn’t know what they are doing.

In the end yes this matters and it matters a lot. A friend of mine from my old job left and is seeing about 6 RVUs per hour and seeing more patients and higher acuity. The amount of money the hospital is leaving on the table is staggering.

I think using the term aggressive makes it seem unscrupulous. I would argue if you have someone who knows what they are doing it is just billing appropriately. It’s like asking a FP doc to do a central line and they tell you it is hard whereby you ask an ED doc and he would say it was standard.

With experience you can do a better job.
 

MechEDoc

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I will be very cautious to take a 100% RVU job - or any RVU based job if there isn't true transparency. I've had friends with a large CMG suddenly have their compensation drop by $50 an hour due to an unspecified (and never clarified despite repeated requests) change in the calculations. This prompted all of the long-term physicians at the facility to redouble their efforts in both quickly seeing patients as well as aggressively charting critical care time, etc. Understandably this benefited the CMG greatly, led to decreased quality of patient care and some questionable charting.
 
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Hercules

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When we were a private SDG, we started with 100% RVUs but then you start getting discontent with docs in poor payer mix, docs fighting for charts, docs chart watching, docs not picking up Low RVU charts.

Its a bad practice that pits docs against docs.
I work in a SDG that is almost 100% RVU (other than a lathe night shift differential) and wouldn’t have it any other way. As long as it’s a completely transparent, it’s hard to argue you’re getting treated unfairly. Also, payer mix has nothing to do with RVU based payments. Your productivity should be assigned by what you bill not what you collect.

CMG would be a completely different story. Anytime I moonlit with them I always demanded ridiculously high hourly rates.


Sent from my iPhone using SDN mobile
 

emergentmd

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I work in a SDG that is almost 100% RVU (other than a lathe night shift differential) and wouldn’t have it any other way. As long as it’s a completely transparent, it’s hard to argue you’re getting treated unfairly. Also, payer mix has nothing to do with RVU based payments. Your productivity should be assigned by what you bill not what you collect.

CMG would be a completely different story. Anytime I moonlit with them I always demanded ridiculously high hourly rates.


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Payer mix is important when Hospital A has alot of insured and Hospital B has less. Where I worked, if both had the same volume, hospital A always made more $$$$.

I too am for RVUs but you have to really give a huge night bonus b/c RVUS drop right at 2am.
 

Hercules

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Payer mix is important when Hospital A has alot of insured and Hospital B has less. Where I worked, if both had the same volume, hospital A always made more $$$$.

I too am for RVUs but you have to really give a huge night bonus b/c RVUS drop right at 2am.
Best practice is probably where your group (hopefully a SDG) combines all revenue into the same pot and then pays out productivity based on RVUs generates regardless of the site where you generated them. This eliminates the payor mic issue. Whether hospital A or hospital B makes more money doesn’t matter if you are a separate private group that staffs both of them.

As far as large night shift bonus, ours is an extra $50/hr and makes you feel better about a slow shift but doesn’t incentivize any of us to pick up extra nights. I could bump it to a $100/hr differential and it still wouldn’t move the needle. We’re always looking for a nighthawk or two, though.


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