A landmark decision in my workplace

zenman · Apr 16, 2012

Are the corporate guys physicians or suits?

Spoiled1, MSN, RN · Apr 16, 2012

I know this is random, but I am in NC and looking to apply to Duke's FNP program over the next year or so. Do you mind sharing with me your impression of the program?

I'd be interested to hear what's really like. Please feel free to PM me. Thanks.

We found out on Friday that our corporate pay schedule is being completely revamped and NPs and MDs/DOs in any given specialty will be paid the same, weighted according to experience, not educational path. MSN/DNP prepared NPs will earn the same as MDs/DOs with the same amount of time in practice. Post graduate residency does count toward years of experience, as do fellowships. My "residency" was part and parcel of my graduate program, i.e. pre-graduation, and would not count. They way it was explained to me is that the corporation sees no effective difference between the physician in his/her first year of practice after a 3 year family practice residency and the NP with 3 years experience.
Salary varies widely according to specialty. I am in family practice and we are at the bottom of the salary tiers, but I am about to get a 28K a year raise, effective July 1st. Some of the specialties do not have NPs, so it doesn't apply-surgery for instance.
Bonuses will be paid on productivity and billing/collections, and be completely unrelated to level or type of education. They also threw out the patient satisfaction component. All that matters now is how much revenue one generates for the (for-profit) company. This is a very large corporation spanning two states, with 9,000 employees. It was approved by the board of directors that is almost entirely (11 physicians and 1 NP) made of up physicians- and it will be interesting to see how many of our competitors follow suit in the next few years. If this is the future, one would have to be absolutely crazy to go to medical school and then enter a low paying specialty like family practice/pediatrics, etc.
I think NPs might also have to be crazy to stay in backward states that do not allow for NP independence. I will be earning twice what my Duke classmates who stayed in NC earn, and have complete autonomy while I think the North Carolina NP practice act still calls for "supervision."
I suspect the dominos will start falling soon. States that restrict practice and income will not have any providers at all, and with health care reform coming to fruition around the corner, no one can afford to be in that position.
Unfortunately, the organization sees PAs differently and they are not included in the restructuring. There is one CNS (in diabetes) and she was not included either and I heard she resigned in protest at the end of the day Friday. Both of the states that this organization has offices in have independent provider status for NPs. I assume PAs and the CNS were left out because they cannot be independent providers. This is a real shame, and I hope it will be rectified very soon.

BlueDevil,DNP, DNP, RN · Apr 17, 2012

A mix. the board of directors is almost all physicians (but that is changing too). There are non-physicians in various management positions

TX RN · Apr 17, 2012

Regarding billing:

Does your employer review with providers how much their individual billing codes bring in?

My understanding is not all coding is created equal.

Meaning one 213 from one pt may differ from another pt's 213.

Example:

Level 3 e&m for office visit w/typical diagnosis

Patient A

90213

HTN, benign: 401.1

DMII, not stated as controlled or uncontrolled: 250.00

Nephritis: 583.81 (I think)

Patient B

90213

403.10 (HTN w/renal manifestations)

250.40 (DMII w/renal manifestations)

583.81 (nephritis)

Basically both patients have the same diagnosis but using combo makes a difference.

My understanding is E&M only tells part of the story on billing. How you code your individual diagnosis makes a difference on reimbursement.

core0 · Apr 17, 2012

A a 99213 pays the same regardless how its coded. The diagnoses and the order are important in auditing. The diagnosis along with the time and the level of critical thinking are what determine the level of the E/M. The other portions are to back up the level.

TX RN · Apr 17, 2012

A a 99213 pays the same regardless how its coded. The diagnoses and the order are important in auditing. The diagnosis along with the time and the level of critical thinking are what determine the level of the E/M. The other portions are to back up the level.

Coding and reimbursement is not that simple. I wish it was.

But let me back up a bit. I'm speaking in terms of Medicare/Medicaid reimbursement from CMS. Although this also includes the "commercial" plans that are the marketed medicare advantage plans. So this is a large percentage of any practice's patient panel.

Certain diagnosis will identify HCC-triggers for risk adjustment. CMS adjusts reimbursement rates based on the total adjusted score of the patient panel size from the contracted physician. This scoring affects ALL the patients in their plan, meaning variances in reimbursement.

core0 · Apr 17, 2012

Coding and reimbursement is not that simple. I wish it was.
But let me back up a bit. I'm speaking in terms of Medicare/Medicaid reimbursement from CMS. Although this also includes the "commercial" plans that are the marketed medicare advantage plans. So this is a large percentage of any practice's patient panel.
Certain diagnosis will identify HCC-triggers for risk adjustment. CMS adjusts reimbursement rates based on the total adjusted score of the patient panel size from the contracted physician. This scoring affects ALL the patients in their plan, meaning variances in reimbursement.

Diagnoses do not trigger risk adjustment. The risk adjustment is made up of all the ICD-9 diagnosis that are made in Medicare claims for the entire year. Since, for the most part a provider is limited to four ICD-9s per encounter and the primary reason for the encounter should occupy the first and possibly the second slot, most of the ICD-9s that are entered in the HCC come from inpatient encounters (more specifically the hospital encounter which can contain an unlimited number of ICD-9s). You are correct that the greater the accuracy that you code the ICD-9's the greater the risk adjustment. Ie two decimal precision will result in greater risk adjustment than one. Also conditional ailments do not add to the risk adjustment. So chest pain will not add but MI will.

TX RN · Apr 17, 2012

^^ Core0

Sorry, don't mean to get into a back and forth about coding. As it's unrelated to the OP thread. I brought it up as a question since OP mentioned seeing a lower volume of patients compared to his counterpart.

My intentions were to lead the discussion to explore the idea that x volume is not the same as x volume. Even when they are coded similarly.

But seeing that coding is already complicated in it of itself, I hate to see an opportunity missed to address some common misconceptions.

#1. "...a provider is limited to four ICD-9s"

Not so, you can add many more than just that. Use a modifier to include additional diagnosis above the alloted 4 on the E&M. One additional modifier for each additional set of 4 icd-9s addressed in the visit. As long as you address them in the visit, you can code for them.

#2. "...conditional ailments do not add to the risk adjustment. So chest pain will not add but MI will..."

You give a good example here, totally agree. But, if you diagnose angina as the cause for chest pain, then this will adjust the RAF score.

How this applies to your practice is that it allows your group a stronger position when it renews contracts with managed care organizations. A higher RAF will generate greater revenue not only for the practice but also for the plan as a whole.

jtmarcy12, BSN, RN · Apr 23, 2012

My question is if patient response will no longer matter, what hope does a person have that a patient will be treated fairly, when money will be the focus for treatment? I think NP's deserve to get more pay. I knew of a nurse class mate who worked in a doctor's office after she got her NP license she mostly took care of all the patients in the doctors office while he basically took it 'easy' and took off work a lot, and left her in charge. She quit because he did not want to increase her pay because she was doing all the hard work. I know a lot of times this does happen. Here in CA a hospital tried to hire all Medical Assistants to actually work in the hospitals and fire the RN's, it went to court and they had to rehire the RN's, what if this happens to the MD's? :confused: