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Advice on developing work situation

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  • Avatar OSman 
    Participant
    Status: Physician, Dentist
    Posts: 23
    Joined: 12/20/2018

    Background: I am a dual trained oral surgeon practicing in a small/midsize midwest town since graduating residency in summer 2018. I am employed by a hospital and am in clinic 3.5 out of 5 days and in the OR 1 day with a half day admin time each week. Call is 1 week in 5 and very very manageable. The base compensation and the job are very satisfying. The compensation would likely look better long term in a private practice situation but the scope of practice would not be. Currently my salary has an additional collections incentive. Base pay or 50% of my collections… whichever is higher. Bonus is determined at the end of each fiscal year. By nature of working for the hospital, there is little transparency as to what % is collected. I do see a larger % of medicaid/state medical assistance patients than would be expected in private practice but not so much that I would expect to not meet that collections threshold.

    Additionally, I signed the contract 1/4 the way through my chief resident year and earned a stipend while finishing residency, a sign on bonus as well as all moving expenses paid. A large portion of this would have to be paid back (~40k should I leave the job inside of 3 years).

    It turns out I do have means of tracking some insurance related issues via Epic. It came to my attention that I was not set up as an in network provider for some of the larger dental insurance companies. This has obvious ramifications which when I brought to the attention of hospital administration was originally downplayed. I have continued to escalate the importance of getting this straightened out but the problem of wading through hospital politics, administrators, lawyers, etc is proving to be quite cumbersome. One solution I have brought up that seems to be gaining traction is the idea that we re negotiate my contract to a 1099 arrangement and have me set up my own contracts with payors. Obviously I would require an increase in pay to account for the added expenses of the 1099 arrangement on my end. Further I would ensure to cut out any language penalizing me for an early departure for as far as I am concerned the hospital simply wasn’t ready for my arrival and has not kept up their end of the bargain. I have no plans to leave as I’ve no leave as the job is very fulfilling but I would prefer that flexibility given the demonstrated headache of working for this institution where it is more respected to be a senior vice whatever than a physician…. I digress.

    I would need to continue using the facility, the staff, equipment, etc. I am hoping the arrangement would give me more transparency with billing/reimbursement given I will be the one directly contracted with the payors. I am also hoping as a 1099 I would be shielded from having to fall in line with administrative red tape. I am thinking the best way to arrange this is to simply “rent” the above from the hospital for a set fee/% production similar to my current contract. Rather than having the hospital tell me what my production was and just having to trust them I would be the one tracking production is the thought. Does anyone have any experience with a situation like this? Are there particular areas of my thought process that need massive redirection. Obviously if this continues to gain traction I will need to get representation to make sure done appropriately. As it stands it seems as though I have a little bit of leverage as it seems the hospital is not able to get me contracted and I need to do so personally. Until contracted, we run the risk of losing business to any of the other capable oral surgeons in town who are in network or the hospital subsidizes the difference between in and out of network costs for the patient (this is current strategy) in an effort to not lose the patient. I am trying to make sure I approach this with the greatest care but protect myself and maximize my own interests in the meantime. Any thoughts much appreciated.

    OSman

    #198485 Reply
    Avatar ZZZ 
    Participant
    Status: Spouse
    Posts: 426
    Joined: 06/18/2018

    “By nature of working for the hospital, there is little transparency as to what % is collected.”
    Why isn’t that addressed in your contract. If your compensation is based on those #’s, you should have access to them.

    “It came to my attention that I was not set up as an in network provider for some of the larger dental insurance companies”
    Feature or bug? Did the hospital just not get this done (plausible) or have they purposely not done so to charge hire OON rates?

    “One solution I have brought up that seems to be gaining traction is the idea that we re negotiate my contract to a 1099 arrangement and have me set up my own contracts with payors.”
    So, why don’t you just go private at this point? If the hospital can’t handle insurance contracting, what else are they screwing up?

    “I am also hoping as a 1099 I would be shielded from having to fall in line with administrative red tape.”
    If you’re working there, you’re still going to deal with their admin. Maybe a little better since you can pick your own insurance and benefits and such, but you’ll still be impacted by their admin ‘points of emphasis of the month’ or other such nonsense.

    “I am thinking the best way to arrange this is to simply “rent” the above from the hospital for a set fee/% production similar to my current contract.”
    Sure, so don’t be a 1099, be a private doc renting resources from them for market rates, no % involved.

    “Obviously if this continues to gain traction I will need to get representation to make sure done appropriately”
    They’re screwing you on your production pay and you haven’t consulted counsel yet?

    “Until contracted, we run the risk of losing business to any of the other capable oral surgeons in town who are in network”
    Why don’t you go into business with one/some of them? You seem to care about how your practice runs, may as well reap the financial rewards and share the burden for doing that with a kindred spirit as opposed to paying for the VP of Meetings and Memos salary.

    #198500 Reply
    Liked by Zaphod, billy
    Avatar MaxPower 
    Participant
    Status: Physician
    Posts: 275
    Joined: 02/22/2016

    Are you aware of how other surgical/surgical subspecialty providers are reimbursed?

    Based on what you have said, it seems that the hospital has little incentive to make sure you are being paid the highest allowed rates, even though they would stand to get a cut of that, particularly if you exceed your base salary in production.

    What about approaching them to be paid for wRVUs? This would incentivize you to continue working hard while allowing the burden of collections to be entirely on them.

    #198523 Reply
    Liked by Zaphod, ZZZ
    Avatar OSman 
    Participant
    Status: Physician, Dentist
    Posts: 23
    Joined: 12/20/2018
    Disability Insurance
    “By nature of working for the hospital, there is little transparency as to what % is collected.” Why isn’t that addressed in your contract. If your compensation is based on those #’s, you should have access to them.

    Click to expand…

    When I signed the contract I didn’t anticipate that being a problem. I figured there would be more clarity. It’s easy to track my non dental code production but I don’t think the hospital is geared toward tracking dental codes.

    “It came to my attention that I was not set up as an in network provider for some of the larger dental insurance companies” Feature or bug? Did the hospital just not get this done (plausible) or have they purposely not done so to charge hire OON rates?

    Click to expand…

    Just dropped the ball and now the red tape is too thick for them to cut through. Its not about getting higher OON rates because they are subsidizing that amount so patient’s aren’t paying extra. Just mere incompetence.

    “One solution I have brought up that seems to be gaining traction is the idea that we re negotiate my contract to a 1099 arrangement and have me set up my own contracts with payors.” So, why don’t you just go private at this point? If the hospital can’t handle insurance contracting, what else are they screwing up?

    Click to expand…
    “Until contracted, we run the risk of losing business to any of the other capable oral surgeons in town who are in network” Why don’t you go into business with one/some of them? You seem to care about how your practice runs, may as well reap the financial rewards and share the burden for doing that with a kindred spirit as opposed to paying for the VP of Meetings and Memos salary.

    Click to expand…

    Like I said the work is very fulfilling. Private practice oral surgery is pretty much just taking out wisdom teeth and placing dental implants. I promised myself going into training I wasn’t spending 6 years of training just to do that. I like doing full scope practice and plan to do so for at least a few years until I give In and go do T and T (Teeth and titanium $$$). The pay as it stands now is better than it would be as an associate at one of the other doc’s private practice. Obviously compared to a partnership that is no longer true… Unless I turn out to be killing it on these bonuses.

    “Obviously if this continues to gain traction I will need to get representation to make sure done appropriately” They’re screwing you on your production pay and you haven’t consulted counsel yet?

    Click to expand…

    I haven’t technically been screwed yet. Bonuses come at end of fiscal year (summer). Based on what I have seen from colleagues though it sounds as if it should be anticipated. Sleeping with one eye open. Personally tracking my production very closely.

    Are you aware of how other surgical/surgical subspecialty providers are reimbursed? Based on what you have said, it seems that the hospital has little incentive to make sure you are being paid the highest allowed rates, even though they would stand to get a cut of that, particularly if you exceed your base salary in production. What about approaching them to be paid for wRVUs? This would incentivize you to continue working hard while allowing the burden of collections to be entirely on them.

    Click to expand…

    I know some of the general surgeons and ENT are RVU based. I am not sure how ortho, plastic surg, and other general surgeons are reimbursed. We have broached RVU topic but the problem is they don’t want to value dental RVU’s appropriately on a dollar per RVU basis. A set of 4 full bony impacted third molars under sedation will run about 2500. Private practice oral surgery collection typically greater than 90% and overhead is close to 50%. Theoretically this should line up with my contract (50% collection vs base pay whichever is higher). That puts 1125 in the pocket but their RVU dental scale is more like 650. Those numbers are based on private insurance. RVU system is much more favorable when treating Medicaid/state medical assistance patients as reimbursements are so low. While I try to do my part in treating MA patients they certainly don’t represent a majority so ultimately I think an RVU system as it stands with the hospital is a big concession on my part.

    #198622 Reply
    Avatar ZZZ 
    Participant
    Status: Spouse
    Posts: 426
    Joined: 06/18/2018

    Sounds like you’re doing your part to get educated and get the best deal possible.

    From what you describe, the hospital admin have zero idea what they’re doing wrt dental stuff. Also, being tied to their collections sucks, because in general, hospital billing departments are inept — as you’r discovered. Figure out how many wRVUs you think to do in a year and what you think that’s worth, then ask them for x$ per wRVU. That will probably be the most easily evaluated and least complex relationship for both sides.

    My guess is they need your OMF coverage more than you need their job, use your leverage and push for a favorable arrangement. You have a valuable skill set, you should reap the fruits of that, the VP of Meetings and Memos shouldn’t.

    #198643 Reply
    Liked by Zaphod

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