Expert Pathologist and Their Consults

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Unty

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I was told a particular prominent pathologist has several hundred consults a day. I understand these experts get paid 200-250 per case. Does this cash go straight to the pathologist? I mean this particular person must be seriously banking if this is the case.

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It all depends on the what the expert has worked out with his/her institution- there is no blanket policy.
 
I was told a particular prominent pathologist has several hundred consults a day. I understand these experts get paid 200-250 per case. Does this cash go straight to the pathologist? I mean this particular person must be seriously banking if this is the case.

Yes academic experts can make hella bank, as much as an elite private practice partner (~600-700k plus benefita) and sometimes much more. But I can't see how it is possible to do hundreds of consults a day. Presumably most are difficult and you would figure would take at least 5 minutes a case to review, dictate, edit and sign out. That would mean the academic baller was working 16 hours a day non stop. Seems unlikely
 
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Isn't that what the slaves (aka fellows) are for?

Yes this is what I was told by the fellow. This amounts to over 50K a day in revenue if you are charging 200-250 a case.
 
I was told a particular prominent pathologist has several hundred consults a day. I understand these experts get paid 200-250 per case. Does this cash go straight to the pathologist? I mean this particular person must be seriously banking if this is the case.

I find it hard to believe that anyone would get 100's per day. I covered consults during residency, and we have a few very, very well known experts and I'd have about 10-20 cases a day to show. Maybe a derm person would get more, where the cases are 1-2 slides each, but I still can't imagine 100's per day.

As for the money, I've been at institutions where the pathologist gets the money and I've been at places where the department gets the money.
 
I think the highest volume consult service is probably Epstein's service and he averages between 60-70 per day, though I think there were really busy days that would hit triple digits.
 
Then why are you sending to him again?

I'm not, dude. I don't know exactly how it works, but I've heard stuff about the GU fellowship at JHU that makes me think the fellows work up the consult cases for the most part. It's just hard to believe anyone is looking at that many consults a day, along with regular service duties.
 
Sorry if it read like I was calling you out; I just question the value of "eminence-based" pathology when His EminenceTM is not actually signing out the cases...
 
Sorry if it read like I was calling you out; I just question the value of "eminence-based" pathology when His EminenceTM is not actually signing out the cases...

As do I, so we're on the same page. But I guess if you train your fellows to think like you, that's good enough. And obviously this type of system works around the country, with fellows working up cases for the big names, then probably showing them a representative slide.
 
As do I, so we're on the same page. But I guess if you train your fellows to think like you, that's good enough. And obviously this type of system works around the country, with fellows working up cases for the big names, then probably showing them a representative slide.

Counting on a trainee to write up a case and then just examining a representative slide seems like a sure fire way to royally mess up a case.
 
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Counting on a trainee to write up a case and then just examining a representative slide seems like a sure fire way to royally mess up a case.

I'm obviously getting away from stuff I know too much about, but I've been told this kind of stuff happens. Perhaps someone with a bit more direct knowledge of these things will be willing to chime in. I agree with you, but it's hard to explain otherwise how someone can see so many cases in their entirety themselves.
 
Fellows at my academic behemoth of an institution do all case write-ups, except for those of VIPs (politicians, foreign leaders, Hollywood elite), which go straight to the experts. Cases in entirety are presented to the experts by the fellows. Said experts decide on the fly how much they need to review, write-ups are tweaked and submitted for typing, to be finalized later.
 
I guess I feel the need to defend Epstein (and by extension other prominent consultants). I think you get your money's worth with his consults. He relies on his fellows to preview cases and won't always look at all parts of a prostate case, for example, which are read as benign by his fellows; but they are well trained and are, if anything, over sensitive to flagging things to be reviewed. He will usually look at all or most of a resection case. The previewing helps speed up the signout, but he's also remarkably efficient as well.
 
And obviously this type of system works around the country, with fellows working up cases for the big names, then probably showing them a representative slide.

That is how my fellowship worked, after a period at the beginning when I was getting up and going. But to be fair, sometimes it was two slides, and sometimes three.
 
Fellows at my academic behemoth of an institution do all case write-ups, except for those of VIPs (politicians, foreign leaders, Hollywood elite), which go straight to the experts. Cases in entirety are presented to the experts by the fellows. Said experts decide on the fly how much they need to review, write-ups are tweaked and submitted for typing, to be finalized later.

I am sorry. I threw up in my mouth when I read politicians are VIP's. :thumbdown:
 
Coming from someone with a lot of direct signout exposure with Epstein. The GU fellows/consult service residents preview the cases. Only the part (i.e right apex, etc) that is the outside pathologist is questioning (cancer vs not) is looked at by Epstein. We often find sneaky cancer that the outside person called benign, which we bring to his attention during signout or really anything that we don't agree with in terms of the original diagnosis. So, if the outside person called a part benign and the fellow/resident thinks the same, then he doesn't look at it. He see's on average 70-80 cases/day and the last time I heard, he was charging around $70-80 for most consults. He does get a cut, but certainly not all of the fee goes to him.
 
He see's on average 70-80 cases/day and the last time I heard, he was charging around $70-80 for most consults. He does get a cut, but certainly not all of the fee goes to him.

Forgive me for this question which is probably based in my ignorance of billing, but, here goes: How is it possible for anyone (Epstein included) to determine how much he/she gets paid for a consult? There are CPT codes for consults (88321, 88323, and 88325) and CMS determines how much will be paid. Insurers typically follow suit. Are we merely talking about consults where the pathologist can't make a diagnosis and his/her group is footing the bill? I guess I thought that those were also billed to the patient's insurer/Medicare, although, now that I think of it, that would be double-billing. Can anyone clarify for me?
 
Coming from someone with a lot of direct signout exposure with Epstein. The GU fellows/consult service residents preview the cases. Only the part (i.e right apex, etc) that is the outside pathologist is questioning (cancer vs not) is looked at by Epstein. We often find sneaky cancer that the outside person called benign, which we bring to his attention during signout or really anything that we don't agree with in terms of the original diagnosis. So, if the outside person called a part benign and the fellow/resident thinks the same, then he doesn't look at it. He see's on average 70-80 cases/day and the last time I heard, he was charging around $70-80 for most consults. He does get a cut, but certainly not all of the fee goes to him.

With all due respect to the awesomeness of a JHU fellow (and I mean that in mostly sincerity - I know they have good fellows there), who says a pgy5 or pgy6 fellow is better than a community pathologist with 10 years experience? As in, what if they both call something benign and it's cancer? I guess I'm just bothered by the notion that someone is sending a case in for expert consult and it's actually being looked at by someone with less experience than them.
 
Forgive me for this question which is probably based in my ignorance of billing, but, here goes: How is it possible for anyone (Epstein included) to determine how much he/she gets paid for a consult? There are CPT codes for consults (88321, 88323, and 88325) and CMS determines how much will be paid. Insurers typically follow suit. Are we merely talking about consults where the pathologist can't make a diagnosis and his/her group is footing the bill? I guess I thought that those were also billed to the patient's insurer/Medicare, although, now that I think of it, that would be double-billing. Can anyone clarify for me?

Reimbursement would come from the department rather than straight billing. All academics are on salary, and the revenue they generate from billing goes straight to the department who then distributes it as they see fit. So if they want to pay Epstein or whomever more per case, they can just do it and pay someone else less. Frequently, most of the revenue generated by academic departments gets siphoned off to researchers, administrators, senior pathologists (who often don't sign out much), and the medical school before a few crumbs trickle down to the surgical pathologists who sign out most of the cases and make way less than the revenue they generate.
 
Forgive me for this question which is probably based in my ignorance of billing, but, here goes: How is it possible for anyone (Epstein included) to determine how much he/she gets paid for a consult? There are CPT codes for consults (88321, 88323, and 88325) and CMS determines how much will be paid. Insurers typically follow suit. Are we merely talking about consults where the pathologist can't make a diagnosis and his/her group is footing the bill? I guess I thought that those were also billed to the patient's insurer/Medicare, although, now that I think of it, that would be double-billing. Can anyone clarify for me?

It varies place by place and consultant by consultant.

In this day and age most big centers will bill the patient's insurance for the consult.
If a patient is Medicaid there are issues about billing across state lines. Also HMO patients often times need insurance approval. Hopkins for instance is very consultee-friendly. You just send them the slides and insurance and then get back a diagnosis. I've tried other places and they call me back and say I need to get permission from the HMO. I say screw that send me the slides back and I'll send it to Hopkins or somewhere else.
 
With all due respect to the awesomeness of a JHU fellow (and I mean that in mostly sincerity - I know they have good fellows there), who says a pgy5 or pgy6 fellow is better than a community pathologist with 10 years experience? As in, what if they both call something benign and it's cancer? I guess I'm just bothered by the notion that someone is sending a case in for expert consult and it's actually being looked at by someone with less experience than them.

I tend to agree. Seems to me he should look at every slide.
 
With all due respect to the awesomeness of a JHU fellow (and I mean that in mostly sincerity - I know they have good fellows there), who says a pgy5 or pgy6 fellow is better than a community pathologist with 10 years experience? As in, what if they both call something benign and it's cancer? I guess I'm just bothered by the notion that someone is sending a case in for expert consult and it's actually being looked at by someone with less experience than them.

Like I said, most consultants answer the specific question from the outside pathologist. On the other hand, does every pathologist in general look at the grossing of all specimens? For example, do you think every pathologist looks at the margins and how they are inked on a lumpectomy. Of course not, the PA grosses it and you trust they did a good job. But, you are putting your name down saying the part they called a margin is actually a margin. We all have to trust others to a certain degree and trusting your hypothetical pathologist with 10 years experience and a fellow who sees around 400 prostate cases/week to call something benign seems logical to me. Remember, I am not talking about trusting someone else to make the primary diagnosis. The outside person already made the diagnosis. That is not why they're sending the case. I cant stress enough how important that is.

As far as billing, usually the referring group is billed. In Epsteins case, he has a contract with a large biopsy mill where he gives them a cut rate ($60-70 comes to mind), but is slightly higher for others.
 
Like I said, most consultants answer the specific question from the outside pathologist. On the other hand, does every pathologist in general look at the grossing of all specimens? For example, do you think every pathologist looks at the margins and how they are inked on a lumpectomy. Of course not, the PA grosses it and you trust they did a good job. But, you are putting your name down saying the part they called a margin is actually a margin. We all have to trust others to a certain degree and trusting your hypothetical pathologist with 10 years experience and a fellow who sees around 400 prostate cases/week to call something benign seems logical to me. Remember, I am not talking about trusting someone else to make the primary diagnosis. The outside person already made the diagnosis. That is not why they're sending the case. I cant stress enough how important that is.

As far as billing, usually the referring group is billed. In Epsteins case, he has a contract with a large biopsy mill where he gives them a cut rate ($60-70 comes to mind), but is slightly higher for others.

You make a good point, and I don't think it's unreasonable what you describe. If it were me, I think I would look at everything, but I'm no Epstein. One reason is that while some community pathologists are excellent, there are some who are unbelievably bad, and shouldn't even be trusted to ask Epstein the right question. I saw a prostate biopsy where the outside person called 6 on a few cores and on another one completely missed obvious cancer. It was then sent to Epstein who called it 9 and picked up the missed one. Then it came to us and we agreed it was clearly at least 9. This case was egregious enough that Epstein's system worked, but how many less obvious mistakes are out there that his fellows might miss? Perhaps not many, but I'm not sure.
 
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