Interventional pain vs inpatient

[Pmrelax]

Currently weighing my options as a graduating resident considering interventional pain vs inpatient rehab. Opposite ends of the spectrum, I know.

Lifestyle is very important to me and I know inpatient rehab offers a lot of flexibility which I value. I like procedures but the thought of having a scheduled patients everyday seems exhausting to me. From what I’ve read it seems that pay is probably pretty similar unless you’re a partner of an interventional clinic in which case it’s higher.

Wonder if anyone could weigh in on why you went inpatient or more towards outpatient / procedures.

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[DMBandFan86]

Pay would be higher as interventional. I mean I trained with academic pain guys making over 750k per year (with stims), but mostly were 375-450+. Nonacademic can be more, especially rural where starting is typically over 500k out of residency + incentives. If you want to work in a popular city then you will likely take a pay cut for a while. Ortho groups tend to pay less and make you do EMGs. There are many discussions on the pain forum about income.

If you want to make the equivalent doing inpatient then you will need to see a lot of people. Which decreases the lifestyle benefits. Actually, I think you likely may end up working more. A great inpatient lifestyle would be seeing 10-14 per day, but you would make under 300k and likely still cover 1 week a month. A 8-5 job would be like 16-20 patients per day and 1 weekend call a month or 1:3 call. That would put you over 50% MGMA. If you become a director then you can also do some admin time to make some extra money. Some of us also do 2 call weekends a month. Still less than most pain docs unless you work really hard.

I originally wanted to do pain, but ended up in inpatient mostly. Many reasons to that. Inpatient Lifestyle can be good as the days are somewhat flexible, but you still have meetings and notes have to be signed on time. I typically work the same schedule every day. I now think about outpatient and would feel nauseous having a M-F clinic schedule. But that is what the interventional days are for to break it up. I do miss being able to do many procedures.

I’d recommend to find out what you love more and do it regardless of the money.

 

[PMR2008]

Pain is not for everyone. I know many docs making 500k+ who would rather take a pay cut and not see that patient population. You can do well regardless of inpatient/subcaute/clinic etc. It just depends on how it is structured. I love clinic but only enough to do it once a week.
If you want lifestyle than hard to beat subacute.

 

[sloh]

Your handle and post suggests to me SAR in the right location would be the perfect job for you

 

[RangerBob]

Currently weighing my options as a graduating resident considering interventional pain vs inpatient rehab. Opposite ends of the spectrum, I know.

Lifestyle is very important to me and I know inpatient rehab offers a lot of flexibility which I value. I like procedures but the thought of having a scheduled patients everyday seems exhausting to me. From what I’ve read it seems that pay is probably pretty similar unless you’re a partner of an interventional clinic in which case it’s higher.

Wonder if anyone could weigh in on why you went inpatient or more towards outpatient / procedures.

This is how I felt about outpatient in residency. Not to mention writing notes/answering phone calls long after the last patient left. On inpatient we can (in theory) round on half our patients, run down to the cafeteria for a muffin/coffee, chat with some coworkers about the news/politics/sports/weather, then go back to finish rounding. And we can change it up each day, spur-of-the-moment. We can round early/quickly and go home early if we're not admitting, taking call from home. Or we can take our time with every patient. If someone no-shows on outpatient, we can't wrap up early unless it's our last patient of the day. We could do other work of course. If we take extra time with one patient, then we're behind now, which I found really stressful.

I enjoy the flexibility on inpatient. Obviously we get more urgent situations on inpatient, but it's not that common. For my personality, inpatient just fit better. For most of my co-residents, outpatient fit better--they didn't want to touch inpatient with a 9ft pole. So it's all in the eye of the beholder which one has the better lifestyle/lower stress.

I also like the team atmosphere on inpatient. It was just more fun having all the RNs, therapists, CM/SW, etc.

I do agree with the above that you can get a better lifestyle for same pay if you found part-time work in interventional pain. I don't think general MSK docs doing occasional joint injections/EMGs make more than IPR.

From a personal standpoint, I'm certainly very happy with my income, and moreso my lifestyle/freedom and independence (as an independent contractor) on inpatient rehab.

 

[Pmrelax]

Wow thank you for all the responses!

I’ve struggled with what to out of residency for a while now. I like the field of PM&R but I don’t love it like I love picking my kid up from school or getting a good work out in. I guess inpatient / sar allows for some of that random space in your day that I value. I’d be lying if money wasn’t a large influence in my decision. It’s seductive thinking about that security.

It’s hard because I want it all. A little bit of interventional, inpatient, even spasticity management and emgs. While also having random times at 2 pm to lay on my couch and just chill. Obviously I can’t do all of that. But prioritizing has been a challenge. What a great problem to have! Probably hard to justify a interventional fellowship if I only did 1 day a week.

Maybe I should re evaluate sar like sloh mentioned. I know there’s some great gigs out there. I’ve looked at some independent contractor inpatient jobs with medicine coverage which feels similar to sar to me tbh. They handle the medicine and evening call and I get to do the rehab stuff. Just on a sicker patient.

 

[Slowpoke]

I'd change careers if I had to do inpatient pm&r again. It doesn't feel like medicine to me. Just a glorified social worker.

 

[RangerBob]

I'd change careers if I had to do inpatient pm&r again. It doesn't feel like medicine to me. Just a glorified social worker.

It certainly requires a different hat than medicine. You have to know your rehab medicine, but then wear your psychologist/psychiatrist/social worker/case manager and MSK/non-interventional pain specialist hats as well. I still feel like a real doctor--and I feel like one who addresses more than just "you're sick, here's a pill for that."

It's not "classical" medicine. That's what makes it much more fun, in my eyes.

 

[DMBandFan86]

I'd change careers if I had to do inpatient pm&r again. It doesn't feel like medicine to me. Just a glorified social worker.

If you look at boredom factor, SNF >> IPR. But yeah, inpatient can be boring too. That’s something to consider.

If you do inpatient you can work solo without IM consultants. You can do all the medicine you want. Most of us just don’t want to be paged all night long for the rest of our lives 5-7 days a week for blood glucose levels or have to drive back in multiple times per night for chest pain. But if it makes it fun or feels like a doctor by all means you can do that on inpatient. You would still get paid the same, just work harder.

The team dynamics on rehab can be great, but at times can be a pain.

 

[sloh]

Worth pondering:

“I am not going to give you a big lecture about the importance of doing what you enjoy to do.
But remember this:

When you start working you care about Money>= Your interest >> lifestyle.

After 10 years of practice and saving north of 2 mil you care about lifestyle >>>>> Money>= Your interest.”

Derm vs rads?

Derm vs rads?

To radiologists, if you could do it all over again and given the option, would you pick derm or stick with radiology? Strictly from a lifestyle/money perspective?

forums.studentdoctor.net

 

[PMR2008]

hard to do interventional without chronic pain. Both pain and inpatient have the highest burnout with inpatient with the highest turn over.
IMO once you get really good at PM&R which could take 5-7 years post residency most things are boring. I have a mixed practice with spasticity, interventional, regen, EMGs, P&O and SAR+admin. The right mix for me but it is not for everyone.

I am 10 years into practice post fellowship and this is absolutely true
“
When you start working you care about Money>= Your interest >> lifestyle.

After 10 years of practice and saving north of 2 mil you care about lifestyle >>>>> Money>= Your interest.”

 

[lejeunesage]

If you look at boredom factor, SNF >> IPR. But yeah, inpatient can be boring too. That’s something to consider.

If you do inpatient you can work solo without IM consultants. You can do all the medicine you want. Most of us just don’t want to be paged all night long for the rest of our lives 5-7 days a week for blood glucose levels or have to drive back in multiple times per night for chest pain. But if it makes it fun or feels like a doctor by all means you can do that on inpatient. You would still get paid the same, just work harder.

The team dynamics on rehab can be great, but at times can be a pain.

This is precisely what I do. I LOVE managing all my patients' medical issues. I consult IM maybe 2% of the time? I just don't think there's enough to do on each patient every day if I do zero medical management.
But, then again, that's how I was trained. We rarely consulted medicine when I was a resident. We did pretty much everything ourselves.

 

[lejeunesage]

Currently weighing my options as a graduating resident considering interventional pain vs inpatient rehab. Opposite ends of the spectrum, I know.

Lifestyle is very important to me and I know inpatient rehab offers a lot of flexibility which I value. I like procedures but the thought of having a scheduled patients everyday seems exhausting to me. From what I’ve read it seems that pay is probably pretty similar unless you’re a partner of an interventional clinic in which case it’s higher.

Wonder if anyone could weigh in on why you went inpatient or more towards outpatient / procedures.

Don't go into pain just for the money.
If you actually love both fluoro and that patient population, do it. Otherwise? Not worth it.

I won't tell you money isn't important. That's just something people tell themselves to make themselves feel better about not having as much as they'd like. But you can make really good money in whatever line of work you end up. I work as inpatient rehab medical director. For the past 2 years, I've been making around $450K gross. Is that all the money in the world? No. Could I make more? Sure. Would it be worth it if I earned more but in exchange I had to do something I hated every day? Not a chance.

Numbers will be a bit down this year, given low census issues, etc, but I have a realistic path to North of $500K in 2023.
Basically, you have to see more patients if you want to make more. That sounds daunting at first but you get more efficient over time. I can round on twice the number I did when I first graduating without batting an eye. I can add SNF rounding if I want more money. I can add IMEs. There are a ton of ways to get extra income. The most important is to find something that doesn't make you want to shoot yourself when you're not counting your money.

Personally, I wouldn't do interventional pain for $2 mil/year. If that was all PM&R was, I'd never have chosen it. But you might feel differently. I never liked procedures, and I knew that on day 1 of med school. Some people would rather leave medicine altogether than do the inpatient work I do every day. Know yourself. Just remember that it's a lot easier to add extra work to your plate where you are than it is to move to a new location and start from scratch in a different line of work.

At the end of the day, assuming you're investing wisely, it wouldn't be hard to put $60K+ into retirement account every year, as long as you don't go into academia or peds or something. If you do that, even assuming only a 7.5% return, you'll have about 1.5 mil after 15 years.

Compound Interest Calculator | Investor.gov

Determine how much your money can grow using the power of compound interest.

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Once you get to the point where your money is working for you, you're not going to be very motivated to work long hours or doing a whole of of things you don't care for just to earn more money. It just won't make sense. I'm not there yet, and this year my investments got bitchslapped by the stock market hard. I can still see that I'll be in a really good position by the time I'm 10 years out of training, though. Knowing now how relatively easy it is to ramp up your income, I'd have stressed out a whole lot less about average compensation etc. when I was in training.

 

[Iamnew2]

Currently weighing my options as a graduating resident considering interventional pain vs inpatient rehab. Opposite ends of the spectrum, I know.

Lifestyle is very important to me and I know inpatient rehab offers a lot of flexibility which I value. I like procedures but the thought of having a scheduled patients everyday seems exhausting to me. From what I’ve read it seems that pay is probably pretty similar unless you’re a partner of an interventional clinic in which case it’s higher.

Wonder if anyone could weigh in on why you went inpatient or more towards outpatient / procedures.

Depends what you like. I will say that the pay factor is a bit of a complex picture. I’m a med director independent contractor and made over $800k this past year. I saw a lot of patients yes but when I was doing fellowship I would see 30 or so people at times and attendings would see an obscene number of people and cover midlevels. I don’t think it’s safe to do that particularly in the pain type of population. High money interventional pain Carries a lot of liability. I have seen Excellent pain docs make a minuscule mistake that has cost them dearly. I personally decided I couldn’t do that. As someone mentioned inpt is not for everyone but if you are good at managing people and patients you can do well in many levels. I frequently do what ranger bob does and round on people in their room, maybe take a small break do some admin stuff, write notes, talk to coworkers and then go back and see people. I don’t do output clinic now but will and it’s a good mix. Yes you have to deal w inpatient emergencies but you also have to deal w that if you stick the epidural needle in the wrong place and have to send your patient emergently to the ER. If you hire midlevel they can write your notes for you - I’m neurotic when it comes to documentation so I do this myself. If you are In a place where hospitals are close some people round at two places and make a bunch of money. Again inpt you have to like it to be able to do it long term. I don’t work weekends as medicine team covers but yes that’s something that most inpt docs have to do roughly once a weekend. Do what u like and or can tolerate for the next 30 years of your life. As a “lady doctor” like vets say, the radiation ☢️ long term was also a concern for me. You’ll be fine doing either. Inpt also has no overhead essentially outside of billing if you are an independent contractor. I have seen interventional salaries similar to inpt - around the 300k range, the rural where no one wants to go maybe higher but most people don’t want to go super rural.

 

[Pmrelax]

Wow, so how high is your inpatient census? Are planning on adding an outpatient clinic on top of that?

 

[DMBandFan86]

Just as a reference, 90% for PM&R without a pain fellowship is about 500k. >800k would be high top 99%.

That would be over 30+ inpatients per day. If you figure 20 min per each follow up per day and 30 min for new patients (with notes and orders done) that’s about 12 hours per day plus medical director work. That’s not counting family calls, meetings, changes in status, or any other inefficiency. Most places expect medical director to be about 10-50% administrative.

 

[RangerBob]

Just as a reference, 90% for PM&R without a pain fellowship is about 500k. >800k would be high top 99%.

That would be over 30+ inpatients per day. If you figure 20 min per each follow up per day and 30 min for new patients (with notes and orders done) that’s about 12 hours per day plus medical director work. That’s not counting family calls, meetings, changes in status, or any other inefficiency. Most places except medical director to be about 10-50% administrative.

Agree this is a crazy high income for PM&R and not an income that is easily attainable. Nor do I think it would it be desirable--you would never see your family (which may be fine if you're young/single/in debt).

It's not something a recent grad should count on/aspire to either. Seeing 30 patient's/day isn't really even ideal for a seasoned attending, in my opinion. Half that is a good "full-time" job. I average about 14/patients per day and find that very comfortable. Some rehab companies will push you to see 20-25 per day. I think that's rough unless you're talking about temporary 1-2 week vacation coverage. Or you just really like to work...

As a new attending, it sometimes took me an entire day to manage just a 8-10 patient service. Now I can cover our 20-person unit when my partner is out and admit 0-4 admits/day and finish at a decent hour (or a great hour if there are no admits!). I'm essentially always home in time for dinner (6:30 at the latest) and rarely if ever bring work/charting home, aside from call.

I had to cover the unit on my own for a while when I was a fresh grad. At that time it was too much. I could either limit admits to two per day, or see about 3/4 of the unit per day. It's not ideal to limit the census, so I chose the latter option. I saw everyone every-other day (Medicare only requires 3 face-to-face visits per week), with the addition of the handful who were sicker/had big med changes/discharging that day, I saw more frequently. I can't say how much more manageable that made my life at that point in time. You obviously sacrifice easy income (you're still responsible for the pt even if you don't see them that day, and they're literally sitting there ready for you to see whenever you want), but it was worth the trade-off.

 

[Iamnew2]

Agree this is a crazy high income for PM&R and not an income that is easily attainable. Nor do I think it would it be desirable--you would never see your family (which may be fine if you're young/single/in debt).

It's not something a recent grad should count on/aspire to either. Seeing 30 patient's/day isn't really even ideal for a seasoned attending, in my opinion. Half that is a good "full-time" job. I average about 14/patients per day and find that very comfortable. Some rehab companies will push you to see 20-25 per day. I think that's rough unless you're talking about temporary 1-2 week vacation coverage. Or you just really like to work...

As a new attending, it sometimes took me an entire day to manage just a 8-10 patient service. Now I can cover our 20-person unit when my partner is out and admit 0-4 admits/day and finish at a decent hour (or a great hour if there are no admits!). I'm essentially always home in time for dinner (6:30 at the latest) and rarely if ever bring work/charting home, aside from call.

I had to cover the unit on my own for a while when I was a fresh grad. At that time it was too much. I could either limit admits to two per day, or see about 3/4 of the unit per day. It's not ideal to limit the census, so I chose the latter option. I saw everyone every-other day (Medicare only requires 3 face-to-face visits per week), with the addition of the handful who were sicker/had big med changes/discharging that day, I saw more frequently. I can't say how much more manageable that made my life at that point in time. You obviously sacrifice easy income (you're still responsible for the pt even if you don't see them that day, and they're literally sitting there ready for you to see whenever you want), but it was worth the trade-off.

Yes, I agree that it's unusual income, and it's been a ton of work. My point was simply to illustrate that (not as a new grad) but that inpatient work can be very lucrative in the right circumstance. Where I work, they freak out if census is not their "target goal" - created by the nonsensical "corporate" team, so there is a constant push for more and more, I only admit patients that are appropriate, so that definitely brings a lot of tension and glad to be leaving this place, as they are constantly trying to have me admit inappropriate patients particularly when census drops - that is one of the negative sides of inpatient, you frequently have to deal with the corporate nonsense. Here they have the medicine team accept inappropriate patents I won't admit, but that's different story.

Point being that I think as you see more and more patients and become more efficient, it's not as difficult to see 25+ patients as day. But I agree its' a lot of work and long days. But in pain you are still seeing 30 plus patients (some practices would tell me they saw 40-50p patients a day!!!!) so 25-30 doesn't seem as bad, particularly on patients you see daily.

I was remembering when I was in residency and would freak out about seeing 10 patients/day and had no idea how I would manage. So the more seasoned you are, the more patients you can see. And the good thing about inpatient is that while you have to see them 3x/week for face to face, if one day you are swamped and can't, as long as they are stable, it's within the acceptable. So for me inpatient wins in this debate.

 

[Iamnew2]

Wow, so how high is your inpatient census? Are planning on adding an outpatient clinic on top of that?

Typically 25-30. Census has dropped recently so working less, but also moving onto a different job which is different and will be a combo of inpatient and outpatient

 

[sloh]

some practices would tell me they saw 40-50p patients a day!!!!

Whoah. Hahaha. I'd pay to just see how a clinic like that functions

 

[Iamnew2]

Whoah. Hahaha. I'd pay to just see how a clinic like that functions

I could never see that many patients. I think in inpatient you see the patients daily and know them so interactions are much quicker and efficient, I can't imagine having to see that many patients in a day - even if follow ups. Yikes! Even in a high census place inpatient definitely has a slower pace.

 

[RangerBob]

I could never see that many patients. I think in inpatient you see the patients daily and know them so interactions are much quicker and efficient, I can't imagine having to see that many patients in a day - even if follow ups. Yikes! Even in a high census place inpatient definitely has a slower pace.

Agree inpatient provides the better lifestyle.

I’ll stick with closer to 15 patients/day though! Keeps me busy enough but with enough free time, and still plenty of income

 

[j4pac]

Agree this is a crazy high income for PM&R and not an income that is easily attainable. Nor do I think it would it be desirable--you would never see your family (which may be fine if you're young/single/in debt).

It's not something a recent grad should count on/aspire to either. Seeing 30 patient's/day isn't really even ideal for a seasoned attending, in my opinion. Half that is a good "full-time" job. I average about 14/patients per day and find that very comfortable. Some rehab companies will push you to see 20-25 per day. I think that's rough unless you're talking about temporary 1-2 week vacation coverage. Or you just really like to work...

As a new attending, it sometimes took me an entire day to manage just a 8-10 patient service. Now I can cover our 20-person unit when my partner is out and admit 0-4 admits/day and finish at a decent hour (or a great hour if there are no admits!). I'm essentially always home in time for dinner (6:30 at the latest) and rarely if ever bring work/charting home, aside from call.

I had to cover the unit on my own for a while when I was a fresh grad. At that time it was too much. I could either limit admits to two per day, or see about 3/4 of the unit per day. It's not ideal to limit the census, so I chose the latter option. I saw everyone every-other day (Medicare only requires 3 face-to-face visits per week), with the addition of the handful who were sicker/had big med changes/discharging that day, I saw more frequently. I can't say how much more manageable that made my life at that point in time. You obviously sacrifice easy income (you're still responsible for the pt even if you don't see them that day, and they're literally sitting there ready for you to see whenever you want), but it was worth the trade-off.

That doesn’t even get into the malpractice and insurance fraud risks. Being well over 90th percentile is definitely a red flag

 

[Iamnew2]

That doesn’t even get into the malpractice and insurance fraud risks. Being well over 90th percentile is definitely a red flag

No, totally legit - this is between med director stipend, guarantee, collections. Simply good negotiation.

 

[j4pac]

No, totally legit - this is between med director stipend, guarantee, collections. Simply good negotiation.

Even if the billing is totally clean…those that are that high above average are at risk for malpractice. Probably more protected while doing inpatient…but Pain? Really high risk

 

[Iamnew2]

Even if the billing is totally clean…those that are that high above average are at risk for malpractice. Probably more protected while doing inpatient…but Pain? Really high risk

I would agree with you that high level billing in interventional pain means high liability - one of the reasons I opted to not do pain. I particularly became concerned with cervical stuff - reimbursement is not that great for some procedures that are high risk and patients don't get that much relief. no thanks. I sleep better at night this way.

 

[RangerBob]

I would agree with you that high level billing in interventional pain means high liability - one of the reasons I opted to not do pain. I particularly became concerned with cervical stuff - reimbursement is not that great for some procedures that are high risk and patients don't get that much relief. no thanks. I sleep better at night this way.

I think what j4pac is saying is just the number of people you're seeing increases your liability. Really only two things are tied to how often physicians get sued: their specialty/if they do lots of procedures (ie, OB), and the number of patients they see.

IPR is relatively low risk (as my $4k/yr liability policy attests to), but seeing 30 patients/day substantially increases your risk compared to someone who sees 15. Unfortunately it doesn't matter if you're competent/nice/spend a lot of time with patients--it all comes down to whether you're doing procedures and how many patients you see.

On the flip side, you may see 30 patients/day, but it's not 30 new patients/day, so in IPR we don't actually see that many patients per year compared to someone running a busy clinic. So realistically your risk of being sued is probably still quite a bit lower than the average outpt PM&R doc even if you're working double-full-time/seeing a large census.

The other thing is to just be careful with your billings. If you bill based on time, you obviously want to be sure you're not billing more hours than there are in a day. My billers had some docs who did that and the billers refused to submit those charges as clearly there was fraud going on. They cut their contracts with those docs. When you're one of the top billing inpatient physiatrists in country (I assume at $800k you are), one would assume there's a significantly higher risk of being audited by Medicare as you're much more likely to be on their radar (similar to the top 1% of any specialty). However, if you're documentation is solid, you'd have nothing to worry about in an audit.

 

[Iamnew2]

I think what j4pac is saying is just the number of people you're seeing increases your liability. Really only two things are tied to how often physicians get sued: their specialty/if they do lots of procedures (ie, OB), and the number of patients they see.

IPR is relatively low risk (as my $4k/yr liability policy attests to), but seeing 30 patients/day substantially increases your risk compared to someone who sees 15. Unfortunately it doesn't matter if you're competent/nice/spend a lot of time with patients--it all comes down to whether you're doing procedures and how many patients you see.

On the flip side, you may see 30 patients/day, but it's not 30 new patients/day, so in IPR we don't actually see that many patients per year compared to someone running a busy clinic. So realistically your risk of being sued is probably still quite a bit lower than the average outpt PM&R doc even if you're working double-full-time/seeing a large census.

The other thing is to just be careful with your billings. If you bill based on time, you obviously want to be sure you're not billing more hours than there are in a day. My billers had some docs who did that and the billers refused to submit those charges as clearly there was fraud going on. They cut their contracts with those docs. When you're one of the top billing inpatient physiatrists in country (I assume at $800k you are), one would assume there's a significantly higher risk of being audited by Medicare as you're much more likely to be on their radar (similar to the top 1% of any specialty). However, if you're documentation is solid, you'd have nothing to worry about in an audit.

Definitely understand your point. My clinical billing is in tune with most other PM&R docs, what makes up the difference is a healthy med director stipend and a significant guarantee (neither of which I bill for, the hospital pays me that).

 

[DMBandFan86]

I’ve seen independents have a guarantee, but only until they produce and then it goes away. You make it sound like you are getting a base salary + all collections + med director. I haven’t seen a gig like that, but where can I sign up lol?

 

[Pmrelax]

Ya that’s high census. Wouldn’t want that coming out of residency.

I will say in residency over the weekend I write an average of 35- 40 notes per day. Usually 25-30 progress notes and any ipr consults which can range from 3-10 on any weekend day. So I’ve learned how to become efficient seeing patients. For good or bad reasons I guess. But it is what it is. Idk how that’s not Medicare fraud they co-sign a total of 65-70 per day.

 

[Pmrelax]

*attendings co-sign

 

[DMBandFan86]

I think what j4pac is saying is just the number of people you're seeing increases your liability. Really only two things are tied to how often physicians get sued: their specialty/if they do lots of procedures (ie, OB), and the number of patients they see.

IPR is relatively low risk (as my $4k/yr liability policy attests to), but seeing 30 patients/day substantially increases your risk compared to someone who sees 15. Unfortunately it doesn't matter if you're competent/nice/spend a lot of time with patients--it all comes down to whether you're doing procedures and how many patients you see.

On the flip side, you may see 30 patients/day, but it's not 30 new patients/day, so in IPR we don't actually see that many patients per year compared to someone running a busy clinic. So realistically your risk of being sued is probably still quite a bit lower than the average outpt PM&R doc even if you're working double-full-time/seeing a large census.

The other thing is to just be careful with your billings. If you bill based on time, you obviously want to be sure you're not billing more hours than there are in a day. My billers had some docs who did that and the billers refused to submit those charges as clearly there was fraud going on. They cut their contracts with those docs. When you're one of the top billing inpatient physiatrists in country (I assume at $800k you are), one would assume there's a significantly higher risk of being audited by Medicare as you're much more likely to be on their radar (similar to the top 1% of any specialty). However, if you're documentation is solid, you'd have nothing to worry about in an audit.

Also, you make more than a neurosurgeon on avg who probably works 80 hours per week.

 

[j4pac]

I think what j4pac is saying is just the number of people you're seeing increases your liability. Really only two things are tied to how often physicians get sued: their specialty/if they do lots of procedures (ie, OB), and the number of patients they see.

IPR is relatively low risk (as my $4k/yr liability policy attests to), but seeing 30 patients/day substantially increases your risk compared to someone who sees 15. Unfortunately it doesn't matter if you're competent/nice/spend a lot of time with patients--it all comes down to whether you're doing procedures and how many patients you see.

On the flip side, you may see 30 patients/day, but it's not 30 new patients/day, so in IPR we don't actually see that many patients per year compared to someone running a busy clinic. So realistically your risk of being sued is probably still quite a bit lower than the average outpt PM&R doc even if you're working double-full-time/seeing a large census.

The other thing is to just be careful with your billings. If you bill based on time, you obviously want to be sure you're not billing more hours than there are in a day. My billers had some docs who did that and the billers refused to submit those charges as clearly there was fraud going on. They cut their contracts with those docs. When you're one of the top billing inpatient physiatrists in country (I assume at $800k you are), one would assume there's a significantly higher risk of being audited by Medicare as you're much more likely to be on their radar (similar to the top 1% of any specialty). However, if you're documentation is solid, you'd have nothing to worry about in an audit.

100%. The truth is that just about any of us could be hit with fraud if we were really put under the microscope and scrutinized. Billing is HARD. We all make errors with billing. But that’s ok…because very few of us are practicing unethically and very few of our errors are pursued. But when you are producing like a frickin Neurosurgeon…you absolutely will be under the microscope. And those errors that everyone makes will come to light. And there’s no way that you can’t convince me that someone twice as productive as other physicians doesn’t make more simple errors.

True story…I had a prior employer who contractually did not allow its employees to make over 90th percentile. Their reasoning was exactly what has been laid out…and it wasn’t for my employer to be cheap, it was to protect their investment. We could earn over 90th percentile, but there was a rigorous review including an internal audition and board decision before allowing it.

 

[PMR2008]

The word “fraud” is thrown around to often. Per CMS “Fraud requires intent to obtain payment and the knowledge the actions are wrong. Waste and abuse may involve obtaining an improper payment or creating an unnecessary cost to the Medicare Program but do not require the same intent and knowledge.”
Audits are a part of life. Yes you do get more audits if you hit those numbers but if the work is being done and the notes are good there is not much to be fearful of. I know docs who have his those number for 10 years. I personally could never practice that way and I have multiple income streams so I stay under the radar.

 

[j4pac]

The word “fraud” is thrown around to often. Per CMS “Fraud requires intent to obtain payment and the knowledge the actions are wrong. Waste and abuse may involve obtaining an improper payment or creating an unnecessary cost to the Medicare Program but do not require the same intent and knowledge.”
Audits are a part of life. Yes you do get more audits if you hit those numbers but if the work is being done and the notes are good there is not much to be fearful of. I know docs who have his those number for 10 years. I personally could never practice that way and I have multiple income streams so I stay under the radar.

You are clearly confident in your process. That’s fine. I’m not talking directly to you…I’m talking to the forum. There are real risks to producing over 90th percentile of your peers. That’s all I’m trying to illustrate.

 

[sloh]

Pain likely under way more scrutiny than inpatient rehab though

 

[PMR2008]

Also it is not just about how much you get paid. It is how much has been billed. An independent contractor who makes 50% of collection but bills 1.6 million is higher risk than someone who makes 95% of collection and bills 850k and makes 800k. @Iamnew2 has a nice gig where @Iamnew2 kept the vast majority of collections.

 

[Dr. Ice]

Who saves north of 2 mill?! That’s something. Are you including your house in that? I’ve been working for 12 years and def don’t have 2 million in savings unless you count 401k + home equity + savings/checking, and even then it’s a little shy of that