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Neurohospitalist Part III: The Saga Continues [Administrator shell game?]

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  • Neurohospitalist Part III: The Saga Continues [Administrator shell game?]

    I had the long anticipated meeting with one of my bosses. I left the meeting happy that we seemed to working in a positive direction. However, I am waiting for an in-writing offer (expected Mon/Tues) in order to be able to analyze what is actually being offered. However, I feel like I may have been played for a fool.

    Take Home Points:

    - They want me to stay and are happy with my clinical and leadership contributions to the hospital

    - They understood my "demands" and that I was asking for a total compensation package in the range of $400k/year

    - They are not going to give me that entire salary guaranteed, but want to help bolster productivity bonus opportunities to get to that threshold

    - The main way to accomplish the boost to productivity bonus threshold is to decrease my FTE appt to 0.9 and decrease my wRVU bonus threshold 10%

    - No mention of being paid stipend for medical director

    - I was quoted my current total compensation (Base salary, Call Pay) is at the 50-55% MGMA percentile.

    *** I get paid base pay $260k and I get paid to be on call $500/night *** I made about $300k when combining base pay and call pay which I was told is 55th-percentile per MGMA per my boss. I do not have access to this data and obviously the person who is telling me this is not acting in my best interest.

    Note: This seems a bit odd. I could be on call every night and make $182,000. Does that mean they would only make my base clinical pay $128,000? Seems like a swerve to me to make it appear I am being compensated fairly when I am working my tail off. I did not recognize this in the meeting so I did not question this at the time, but now it is striking me as a bit odd.


    On the surface it seemed like a productive meeting. It was amicable and had a positive tone. However, I feel like there may have been a "shell game" going on that I felt good because it was a positive meeting, but really it seems like the only thing that they are offering is a decrease in my productivity threshold by approximately 500wRVUs. I feel like I may have been bamboozled.


    Questions that I have for the forum:

    1. When they quote MGMA and other comparable sites does that generally include total compensation (i.e. base pay, call pay and productivity bonus)?

    2. Do the MGMA salary information include pay for Medical Directorship?

    3. Should I consider my call pay to be separate from the median

    4. Is this a win in anyway?

    5. Given the stark law (I think this is the one), they cap my max total compensation at the 90th-percentile. Is there a way to get the stipend for medical directorship not to count against that cap total compensation?


    Important Update about my Productivity: For the first year as an attending I was instructed by my office people and other supporting staff to use the coding option to allow the coder to generate my billing code. That was part of the appeal as a new attending that I did not have to learn billing and I could "focus on my patients." I felt frustrated and burned out because I was working so hard but productivity was at 30th percentile. I asked for some education sessions and I met with the people who were doing my coding. They just kept telling me that I am doing great. I reached out to leadership multiple times trying to understand the issue. Fast-forward to Spring 2019 and I review my own numbers. I do not do procedures, so I just see hospital new consults and follow ups. I see 45% new consults 55% follow ups. I was only averaging 1.75wRVU/clinical encounter. This led to me educating myself and doing my own coding. I essentially started to choose the level of my consults myself. There are still back-end things that the coders do (i.e. observation codes being changed to whatever their CPT, Medicare versus private insurance etc.).

    I made the switch in mid-June 2019. I was averaging about 400wRVU for the preceeding 11 months. In July 2019, the first full month I did my own billing, I posted 685wRVUs. There seemed to be some end-of-fiscal year lagging so I probably actually did closer to 580ish for the month. Regardless, nearly a 50% increase. My volumes did not change in any meaningful way. I suspect this is in direct result to my coding changes. When I retrospectively look at last year's volumes, this billing debacle likely resulted in ~$50k productivity bonus.

    Important Professional Update: I was cold called by 3 people who know me and know that I am a good clinician. They did not know that I was contemplating leaving my current position. I essentially have guaranteed jobs if things fall through where I am now. I have not engaged in an active job search at this point yet, but I am sure I could get a lot of competitive offers elsewhere too. I was just featured in the local newspaper about our stroke program winning the AHA's highest award and I just gave an interview about one of the patients that I helped by utilizing MRI triaging for stroke treatment 12 hours from last known normal in a wake up stroke to be published at a later date.

    Some Ideas for Counter-Offer:

    1. I still think I should be paid an additional $30k stipend for being the stroke medical director

    2. I think I should ask for a $50k retention bonus

    3. Not sure who to weight call and base clinical pay


    I incorporated your feedback before and it did empower me to ask for a ~30% raise. They do truly seem to want me to stay. I would prefer to stay as well. However, I fear my inexperience and naive nature could lead to me making a mistake in analyzing what they are truly offering.


    Appreciate all your time and help as always. I am very grateful for the guidance.



  • #2
    Idk if the medicare cap is different for different specialties, but you're not anywhere near in danger of touching it. In my contract my "cap" is 926K, which is only a cap in that it triggers an audit, for which they see I get paid for $/rvu straight, and they write the check if over (its not just saying how it works).

    You're viewed as a sucker and you just got the pleasant tone, bad information meeting, think of it as a death cab for cutie type interaction, sounds upbeat, but is actually sad.

    Take your reputation and recent media highlights and get some more offers. Only then will you see what the current hospital is actually willing to offer. They sound pretty terrible or somewhat typical I guess.

    They do want you to stay, they want you to stay and not pay you much at all. This is an excellent deal and theyd be foolish to pass on it.

    Good on you for doing your own coding. I dont let coders do anything. We have to pick our outpatient billing levels and on op notes I write all the cpt codes down as separate section of the note. Doing an online course was one of the first and best things I did after switching from cash. It helps you focus documentation, ie, takes very little to generate a level 4 visit once you know the how/why. I see lots of mini novels that only code to a level 2 since authors have no idea, or others trying to use a long time etc...unnecessary.


    • #3
      I cannot advise you regarding numbers for your specialty so I will leave that to someone else. However, I like how your strategy is taking shape. Cordial tone is always a good thing if you want things to develop favorably. Use data whenever needed. Develop multiple BATNAs. Never agree to something unless you truly understand it, which means thanking them for a positive meeting and checking with other folks before making a decision like what you are doing. You know what they say...if you don't know who the fool at the poker table is, it means it's you. These people you deal with have nothing else to do the whole day but play games and they know how to excel at that. We are rookies compared to them since we have actual business to conduct during the day. I also like that you are taking charge of your coding. Never rely on anyone else for your livelihood. Perhaps spend a few more months in the status quo so that you can learn your actual productivity once the correct coding is applied. This will help you formulate a most beneficial plan moving forward. Hard to talk about your current productivity numbers and incorporate them into a bonus structure if those numbers are not correct. Keep it up but don't be in a hurry at this point, I feel like you need more data points. This will help you whether you stay or whether you jump ship.


      • #4
        Agree with above. Kudos for pushing for change and asserting your value. You are way ahead of the curve for most employed docs. We are trained to be agreeable, and the administrators are trained to keep you most satisfied for the lowest cost to them.

        Sorry that I do not have more specific advice to add on to the posters above. I still struggle to understand MGMA data and the finer points of Stark law. I agree completely about seeking a retention bonus, seeking other offers, and most importantly, taking your time and utilizing this forum and your own personal network. The neuro sub-forum on SDN might be helpful also.


        • #5
          "1. When they quote MGMA and other comparable sites does that generally include total compensation (i.e. base pay, call pay and productivity bonus?"

          You realize what you put parenthetically is NOT total compensation. Total comp is the value of all your comp -- pay, benis, retirement c9ntribution, etc.

          Ignorance and incorrect usage of terminology is why admins destroy docs like you in these negotiations about compensation. You don't even know what you want or how that compares to others in the real world doing similar work.

          Come in with specific demands of what you want and the work you're willing to do. Don't get snowed by all their MGMA percentiles and other inaccurate survey data. Know your value, ask for reasonable total comp, and be willing to leave if they won't give you what you think is fair. If you're half as good as you say you are, and they'd have a hard time replacing you given the locale, then 55% MGMA is frankly insulting.

          Tell that what you want and be ready to leave. You've got leverage, use it.


          • #6

            In my contract my “cap” is 926K,
            Click to expand...

            It is about $460k for me.

            You’re viewed as a sucker
            Click to expand...


            I see lots of mini novels that only code to a level 2 since authors have no idea, or others trying to use a long time etc…unnecessary.
            Click to expand...

            That was my issue. I asked for education on how to do better but they were utterly useless. Now I know the key. I make it a fun game to make documentation more tolerable than the normal soul sucking endeavor it usually is.

            I like how your strategy is taking shape.
            Click to expand...

            I think it is pretty apparent that I suck at negotiating in person. I at least have bought some time to figure out I am getting played.

            Ignorance and incorrect usage of terminology is why admins destroy docs like you
            Click to expand...

            Buying myself time is why I come here to get brutal honesty in order to mitigate my own inherent flaws as a negotiator.

            You don’t even know what you want or how that compares to others in the real world doing similar work.
            Click to expand...

            This is what I asked for based on my research on what I feel my own inherent value is as a doc in my field. Where I made the mistake is getting distracted and excited that he was saying that I can make the money I want to.

            Proposed Adjustments to Compensation

            Annual Base Salary: $325,000.00

            Call Pay: $500.00/day

            Annual Stipend for Medical Directorship(s): $35,000.00

            Productivity Threshold: 50th Percentile for Neurohospitalists (If no data available, decreasing down to MGMA 50% which is ~4650)

            Productivity Bonus above Threshold: $45/wRVU

            Maximum Total Compensation (i.e. Salary Cap): None


            • #7
              Who is going to be the medical director if you don't do it? I would probably stop being the medical director to send a message that you mean business. I would also have some other avenues lined up, too. Admins hear docs talk all the time and they know talk is cheap.


              • #8
                Be sure to ask for more than you are willing to accept because they will likely only meet you half way.


                • #9

                  Be sure to ask for more than you are willing to accept because they will likely only meet you half way.
                  Click to expand...

                  Some say 35% higher, then negotiate down in 3 steps to your actual target.


                  • #10
                    35-> 34-> back to 35%....


                    • #11
                      Is 460k really 90th percentile? Crazy.


                      • #12

                        Is 460k really 90th percentile? Crazy.
                        Click to expand...

                        Neurology is non-procedural based specialty largely. I do not have access to the data though. It is a lower paying specialty.


                        • #13
                          Love how admin always quotes the 50% mgma pay as if that magical number makes everything okay.


                          • #14

                            Develop multiple BATNAs
                            Click to expand...

                            Agree with above.
                            Click to expand...

                            You realize what you put parenthetically is NOT total compensation. Total comp is the value of all your comp — pay, benis, retirement c9ntribution, etc.
                            Click to expand...

                            I agree with all of the above posts, and these 3 stuck out to me.

                            What do you want to do all day? Work there? If not, leave. Simple. (May not feel that way... but you have options.)

                            I'd like to be paid more, but when I look at total compensation, it isn't bad, the job is low risk, and I get to have a lifestyle I enjoy. Sort of a balance approach.


                            • #15
                              I also like that you were pleasant at the meeting without actually agreeing to any of their foolishness, that is something to feel good about. Definitely take your colleagues up on offers to interview. The interview process will assist you in not only becoming comfortable dealing with administrator type meetings but also provide valuable information from other facilities with regard to compensation and expectations while meeting new professional contacts. FWIW I haven't ever gone in high and played the meet somewhere in the middle game but rather tell the employer my requirements up front and if they are able to accomodate we have a deal.