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Dear Director,

I get paid based on my productivity, but I don't trust that my company is paying me accurately. How can I check? Do I have the right to look at the books?

open-book-main

In 1999, I was on a 100% RVU-based pay with a national contract management group that none of us trusted. (Incidentally, they went bankrupt several years later.) We spent countless hours collecting our patient labels and then comparing them to the dot-matrix printer pages we were mailed each month. This “official” list of patients that were billed under our name also contained the RVUs associated with the patient. After comparing data for about six months, I, and most of my colleagues, realized the billing company had done a pretty good job and it wasn’t worth our time to compare our patient lists to the ones they mailed us.

The only way the relationship between an employee and their employer will work is if it is built on trust. We must trust each other to do the right thing, and our actions must reflect that unspoken contract. Your bosses trust you to care for the patient and document accurately and appropriately so they can bill the patient fairly. You trust them to pay you based on accurate coding of all of the patients that are billed under your name. If you feel that your employer is not living up to their end of the program, they clearly need to prove to you that you’re being treated and compensated fairly or it’s likely that you will quit. Even worse for the company would be if they developed a reputation for being unfair to their employees regarding compensation. This would result in others quitting, a difficulty recruiting, and ultimately the loss of the ED contract. Remember, they are motivated to retain employees since turnover costs the company money in recruiting and training. It’s estimated that each new doc costs $50-100K (or more if you’re in a far-flung locale). In other words, your employer is highly motivated to treat you fairly, rather than drive you away.

I learned a few lessons from my foray into the books. Pretty consistently there were a patient or two that I saw each shift (5+%) that didn’t make my billing list from the company. Companies expect that 2-3% of ED registrations will not be billed. Some of these are patients who leave without being seen. Other patients present with non-billable visits such as suture removals or packing changes. Some other reasons I lost out on patients were that another doc took credit for the patient after the sign-out process. Your sign-out process should be consistent and fair. Other times, the paper chart was incomplete or lost and the case was never billed. With paper charts, it also wasn’t unusual to find an extra patient or two that I was given credit for inappropriately, sometimes actually giving me a net gain. Coders ultimately have to assign the credit to the right physician so they either must recognize a signature, a written code, or best case, a typed EMR time stamp. Fifteen years ago it wasn’t unusual to physically lose a chart, but that shouldn’t happen now nor should there be an issue with a coder not being able to identify a signature. I also learned that although our pay arrangement had nothing to do with collections, it was tied to billable patients. Therefore, if we provided care to a hospital VIP or a patient who complained and their charges were being waived, we wouldn’t get the credit. This didn’t happen often but was an interesting fact to find out after the contract started.

As a chairman, I’ve had a few doctors through the years complain about not getting paid for all of their patients. I think the only way management can address this is to perform an internal audit. This is time consuming but is critical for the company to maintain credibility with their employees. Just as I did 15 years ago, the company needs to sit down with a list of patients from the provider and compare it to the list of patients billed by that provider. Additionally, the company needs to be able to explain any mismatch. Each time I’ve been through this with my employees, they’ve walked away reassured that the company was accurately catching all of their patients.

Harder for us to judge is how accurately the billing company is capturing charges. This can range from an inappropriate level of care, billing critical care, or failing to capture the billing for procedures. It’s important for your company to be auditing this, too. Given the amount of revenue potentially impacted, I’m sure that your company and the coding/billing company are acutely aware of the importance of capturing every charge and is doing their best to do so.

Massive Chart loss

Implementing a new EMR or switching coding companies has the largest potential to put a major glitch into the data that your pay is based off of. Sometimes, charts can get lost for weeks, or weeks of data can be lost completely. In instances like this, it’s important to have a conversation with your company. A good standard is for companies to anticipate chart issues for 30-60 days and they should consider paying a flat rate until the chart flow can be guaranteed reliable. Reliability often comes down to the company having an effective, hard-wired reconciliation process to insure that each chart is processed appropriately. Ultimately, I expect every company to do the right thing and recognize that either a delay occurred or data was lost and provide the appropriate compensation to the physician.

Opening the books

When you sign a contract to provide emergency services, you’re generally negotiating your best rate and benefits package. You’ll likely be paid based on the competitive market environment in your area. Your contract will also spell out whether you have access to the company’s books or not. I suspect only the minority of emergency physicians ever review the revenue and expenses of their facility or group in detail. My brother works in business. He’s not interested in any business venture with a profit margin under 20%. Healthcare typically runs less than 10%, often closer to 5%, so there really isn’t a lot of extra money floating around padding the coffers of the top brass. I believe it’s more important to know that you’re receiving competitive pay. Medicare opened their data on physician payment in April of this year. I took 20 minutes and downloaded the Excel file of all of the physicians whose last name starts with S. Using my NPI, I found a ton of Medicare billing and payment info related to me. As an aside, the New York Times has a much easier to use web based search though it doesn’t contain all of the information included in the Excel file. With that said, I was reimbursed $45,000 by Medicare in 2012. Like most government websites, this was probably old data since it listed me by a hospital I left in early 2011. Anyway, it’s always eye opening to see what we charge (average $300-600/pt) compared to what we get reimbursed (average $51-139/patient).

If you’re an attorney or an accountant whose firm bills your time at $400/hour, it’s highly unlikely that you’re seeing anything more than a fraction of that amount in your paycheck, unless you’re a partner in the firm. If you work for Google, you’re not getting into the weeds with the CFO to argue that your work made the company more money and therefore you deserve a bigger share. In both cases, employment contracts spell out the compensation prior to the work being done.

As an administrator, I’ve had pretty good insight into my department’s revenue and expenses. I have access to our average charge, average collection per patient, and provider productivity so I can see the exact relation- ship between collections and the amount paid back to the doc. I also see the expenses the company handles on the provider’s behalf. The typical doc in my ED does not see the books. They know what the fair market value is for their job and they have to trust the company to accurately track their productivity and pay them what they believe they’re worth. If they don’t like the arrangement, they have the choice of leaving. While I’ve had doctors quit before, leaving over a belief that the company is unfair, or is inaccurately paying them, is very rare.

In the end, you have to be assured by your company that they are accurately billing your productivity. This has to do with capturing the appropriate codes for each patient seen. If you believe there is an issue, your company needs to do an audit until you are assured you’re being treated fairly. Because of the financial and emotional cost of employee turnover, it’s in the company’s best interest to retain their docs. They can only do that if they treat you fairly and you have trust in them to handle these matters accurately.

Michael Silverman, MD, is a partner at Emergency Medical Associates and is Chairman of Emergency Medicine at the Virginia Hospital Center.

 

Comments   

# Past President AAEMRobert McNamara, MD 2014-08-05 02:39
The question was not answered, do I have a right to look at the books? All physicians are responsible for honest billings, the Feds expect you to be a check on fraud. If you don't see the books you are being ripped off or should I say you are an unwitting participant in illegal fee-splitting. If the money goes to lay people in many states you are abetting the illegal corporate practice of medicine. So yes you not only have a right but a duty to look at the books. Unfortunately, the specialty has let it come to pass that attempting this will get you fired or threatened with termination. We have allowed the "companies" to control huge swaths of EM practice and act in a manner damaging to a profession.

Don't believe this small profit margin pablum, if it was "reasonable" you would see the books. Try 15-20% in most circumstances. You were the one who went to medical school and who is at the bedside at 3 AM on a Saturday night yet the "company" has decided you should not see what is billed and paid in your name. Because if you did see it you would question why that amount of your labors is going to enrich the company. Now turn to the job ads and look at the meetings and their reception sponsors, etc. and you will see just how far down the road the specialty has been sold. In EM, AAEM stands alone against this corporate tide.
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# MD, FAAEMJ Pruitt 2014-08-06 22:44
"If you’re an attorney or an accountant whose firm bills your time at $400/hour, it’s highly unlikely that you’re seeing anything more than a fraction of that amount in your paycheck, unless you’re a partner in the firm. If you work for Google, you’re not getting into the weeds with the CFO to argue that your work made the company more money and therefore you deserve a bigger share. In both cases, employment contracts spell out the compensation prior to the work being done."

Which makes the best argument yet that EM physicians SHOULD be partners in their firm and SHOULD NEVER be employees. Here's the deal ... I'm not an attorney in a large firm, and I don't work for Google. I'm a physician. I went to medical school and residency. I take care of patients. And, I'm also a partner in my company and I do look at the books. Often. Dr. Silverman, you and your "company" won't have to worry about my checking your books, because I never plan to work for you ... or any other corporation. And, just for what it's worth, I don't trust you.
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# RE: How Do I Know if I'm Being Paid Fairly?Russ Mcune 2014-08-06 15:14
Absolutely, Robert. And that is why I don't work for a contract management group and all dues/donations go to AAEM.

I have a problem at one of the hospitals I work at. Funny how some of the other docs are suddenly interested in AAEM.

WE HAVE TO LOOK AT WHAT IS BEING BILLED IN OUR NAMES. Knowledge is power.
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# Attending physician ED 25 yearsDr Sourbutt 2014-08-06 15:33
As my Org Chem professor at THE University of Tennessee (Dr. Eastham, MD PhD ) used to say..."You need to figure out..who is doing what to whom and who is paying for it"
Also my Uncle Bob Hildeman (car and condo salesman in St Pete) would opin...
"Money doesn't talk...it screams"
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# MD, FAAEMJ Pruitt 2014-08-06 22:48
"If you’re an attorney or an accountant whose firm bills your time at $400/hour, it’s highly unlikely that you’re seeing anything more than a fraction of that amount in your paycheck, unless you’re a partner in the firm. If you work for Google, you’re not getting into the weeds with the CFO to argue that your work made the company more money and therefore you deserve a bigger share. In both cases, employment contracts spell out the compensation prior to the work being done."

Which is one of the best arguments I've ever heard that EM physicians SHOULD be partners and SHOULD NOT be employees of a corporation. You see, Dr. Silverman, I DO want to see the books. And, guess what? I get to, because I AM a partner with my company. I'm not an attorney at a law firm, and I most certainly don't work for Google. I DO get to determine the value I add to our company. But, don't worry, Dr. Silverman. I won't be checking your books any time soon, because I never plan to work for your corporation. And, for what it's worth, I don't trust you ...
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