Help! Contract negotiation

Advanced Practice Columnist / Guide · Mar 30, 2012

First off, I don't work in nursing facilities. The opinion I'm giving is based on results of my personal online search regarding the billable dollar amounts that correspond to the services you will be providing. I have very limited understanding of nursing home billing.

To me, this is outright disrespect on that physician's part of your worth as a provider. Not only is this person so greedy to take away more than 50% of the cash value of the services you could be billing for, he is arrogant enough to make you work under a 1099 agreement making you an independent contractor.

Physicians and nurse practitioners use CPT Codes to correspond to the type of Evaluation and Management they provide in nursing facilities. For example, an initial visit is 99304 to 99306 and subsequent visits are 99307-99310. Discharge day visits are 99315-99316. Other nursing facility visits are 99318.

There is a cash value attached to those CPT Codes. The 2011-2012 rates are avilable online if you do a search:

[TABLE]

[TR]

[TD]

Code

[/TD]

[TD]

2011 Pay

(CF =33.9764)

[/TD]

[TD]

2012 Pay

(CF =34.0376)

[/TD]

[TD]

Change in Pay

2011-2012

[/TD]

[TD]

% Change in Pay

2011-2012

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99304

[/TD]

[TD=width: 125]

$88.00

[/TD]

[TD=width: 130]

$89.86

[/TD]

[TD=width: 103]

$1.86

[/TD]

[TD=width: 117]

2.1%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99305

[/TD]

[TD=width: 125]

$123.67

[/TD]

[TD=width: 130]

$126.96

[/TD]

[TD=width: 103]

$3.29

[/TD]

[TD=width: 117]

2.7%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99306

[/TD]

[TD=width: 125]

$157.31

[/TD]

[TD=width: 130]

$161.00

[/TD]

[TD=width: 103]

$3.69

[/TD]

[TD=width: 117]

2.3%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99307

[/TD]

[TD=width: 125]

$42.13

[/TD]

[TD=width: 130]

$42.54

[/TD]

[TD=width: 103]

$0.41

[/TD]

[TD=width: 117]

1%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99308

[/TD]

[TD=width: 125]

$64.89

[/TD]

[TD=width: 130]

$66.03

[/TD]

[TD=width: 103]

$1.14

[/TD]

[TD=width: 117]

1.8%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99309

[/TD]

[TD=width: 125]

$85.28

[/TD]

[TD=width: 130]

$86.80

[/TD]

[TD=width: 103]

$1.52

[/TD]

[TD=width: 117]

1.8%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99310

[/TD]

[TD=width: 125]

$126.39

[/TD]

[TD=width: 130]

$129.00

[/TD]

[TD=width: 103]

$2.61

[/TD]

[TD=width: 117]

2.1%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99315

[/TD]

[TD=width: 125]

$61.50

[/TD]

[TD=width: 130]

$69.78

[/TD]

[TD=width: 103]

$8.28

[/TD]

[TD=width: 117]

13.5%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99316

[/TD]

[TD=width: 125]

$79.84

[/TD]

[TD=width: 130]

$100.07

[/TD]

[TD=width: 103]

$20.23

[/TD]

[TD=width: 117]

25.3%

[/TD]

[/TR]

[TR]

[TD=bgcolor: #FFFF99]

99318

[/TD]

[TD=width: 125]

$90.04

[/TD]

[TD=width: 130]

$91.90

[/TD]

[TD=width: 103]

$1.86

[/TD]

[TD=width: 117]

2.1%

[/TD]

[/TR]

[/TABLE]

For example, if you saw a nursing home resident and coded the visit as 99310, your reimbursement is $126.39 based on 2011 rates. That physician is only paying you $12.00 for that visit, who gets the rest of the $114.39? To me, this is blatantly unfair and bordering on slavery.

Sources:

AMDA: Advocacy - Payment - Physician Fee Schedule

http://www.fmda.org/CMSJA4246Jan2006.pdf

reeya · Mar 30, 2012

Juan, every time I come to allnurses...I see you're always passionately replying in detail helping us students and newbies. A big thank you for your passionate help and thorough knowledge all things concerning NPs. I just wanted to express my gratitude, you are a nurse practitioner.

zlo49 · Mar 31, 2012

Thank you so much for this information!

canchaser, BSN, RN · Mar 31, 2012

WOW Juan I was thinking like a hourly employee. Like if the OP seen 4 pts an hour, which probably could happen in an unsafe environement, they would make 48/hr. Seems the going rate here in the midwest but I like your thinking!!!

PS I totally agree with Reeya.

sailornurse · Mar 31, 2012

Negotiate an hourly rate. Don't go below $50/hr. Locally it ranges from $50 to 85 hr negotiate benefits, he should pay for costs related to maintaining NP licensure: DEA number was $551 last summer when I renewed, here in my state I have to get annual controlled substance from pharmacy board=$60, NP license every 2 years=$193/ OK now what about CEU? In my state I need 50 CEU hours, 15 have to be in pharmacology which means traveling to conferences, at least a minimum of $1500 plus paid time to attend one major conference per year.

What about health insurance????? Vacation time paid????

Like Juan said I don't go to nursing facilites, And I think he has given lots to think about, though I know one NP that does. I say hourly wage but I don't know which isthe better deal but $12 per patient, I don't know what are you required to do and you would have to see 4 per hour to get $48 per hour. Now about the 1099- well this I do know about!! I just got a letter from state taxation department for the jobs at urgent care as 1099. In this state we now have to pay gross receipts tax of 7.75% on the 1099 income, this on top of paying self employment tax, so I would say negotiate this. I owe about 6-7K, my friend is owing 10K for work as independent contractor.

So $48 per hour if you are in the 20% for federal income tax equals $38.20/hr if you see 4 pts /hr. But you still owe state tax, and maybe other taxes. Now as a agency nurse, I made $35/hr as an employee (not 1099).

These are local figures I have given you, and it has only been recently that NP salaries have gone in the higher ranges. Some NP;s are making in the 85-125K locally as employees.

Good luck,

SailorNurse, MSN, FNP

Advanced Practice Columnist / Guide · Mar 31, 2012

Sailornurse,

I was going to comment on that in regards to 1099. I think the OP needs to really look into whether this arrangement is worth it because as an independent contractor, state and federal taxes are not taken away from the $12.00 per patient visit. You have to file and pay taxes due at the end of the year yourself. It sounds like the OP is going to be traveling to different facilities. I suggest she ask her tax preparer how this can work in her favor. Typically, she would be able to claim her car (monthly payments, insurance, gas or mileage) in taxes and all personal items required for the job (laptop, smartphone, etc.). There could be other things that can be claimed (even an office space from home, I think).

Tinabeanrn · Mar 31, 2012

I think that you would need to find out what the reimbursement is for the ECF patients per patient and then find out how much you will should make. I understand why the rate of pay will be fairly low seeing as how you can see so many patients in one day but there are so many issues to consider. I would prefer an hourly wage myself. Other wise you may be making less than you do as a nurse. If the census is low you make only see 10-15 patients per day or less than that. So try to negotiate an hourly wage for sure. And congrats on the job offer! :)

CCRNDiva, BSN, RN · Apr 1, 2012

I agree, with the above posters. Hats off to you Juan :bowingpur

GWL1950 · Apr 8, 2012

Hello all
I'm a new grad NP facing contract negotiation next Tuesday. A doctor who does SNF rounds wants me to do his rounds for him. He is offering me $12/pt (I'll get 1099 form). He says there will be some facilities that have 30 pts all in one place, and there will be some with only one patients. I'm also expected to see new admit pts within 72 hours. And if it is the end of the month, I have to see them before the last day of the month.
He will cover me for malpractice insurance, and he says there will be stipend for health insurance and mileage.
I know this pay is ridiculous, but I need some help gathering information so I can negotiate a better price for my service. I want to know how much I should be asking for per patient and how much I should ask for being on-call. I have no experience or frame of reference. So if anyone out there can help me with this. I'll be so grateful for it.

If you're considering a contractual relationship with another provider, any reason not to have a lawyer - with experience representing NPs - representing you? I'd suggest that any discussion that involves the term "malpractice insurance" should also involve the term "my lawyer" so both parties understand their obligations. If the pay isn't fair, you can quit. If you're involved in litigation, you can't, especially if you are acting as an independent contractor.

TX RN · Apr 10, 2012

Juan is right on the money with this. No pun intended.

I have a moonlighting job that pays by encounter, but I am an employee so they cover malpractice, 401k and social security tax. The latter is what would make you pay a higher percentage into your taxes if you proceed as an independent. I wouldn't do it.

Having also worked hourly, I wouldn't go back from working per encounter back to hourly. The $$ is ridiculous if you can negotiate per encounter. There are 4 things to negotiate for in your contract.

1. Subsequent visit encounter

(this will be a smaller amount but should be in the mid 30's-40's if employed or higher if contracted as independent)

2. Admit encounter

(depending on the complexity and respective E&M coded, this could be in the $100 range per encounter)

3. Discharge encounter

(again, depending on complexity this should range in the $100 range)

4. Coverage and call.

(Most groups will not reimburse you for taking call if you are rounding that particular day. It's simply understood that if you are rounding at a particular facility, you should take call for that facility as well. HOWEVER, I would recommend a cut-off time, maybe 5pm or 6pm. Night call should be reimbursed separately. Also set a max # of facilities you will take call for, depending on historical patient census at those facilities and call volume. Ask for this info, they should know, otherwise they will stick you with the "needier" facilities and you'll feel like a sucker. Ask me how I know.

My advice to you is set a MINIMUM of pt encounters per day, say maybe 15. This will make taking call palatable. If less than 15, you should negotiate an on-call rate.)

Keep in mind that while #2 and #3 will reimburse you more $$ they also require more work. #2 requires you be thorough and gather all relevant information, write up an H&P and make a global plan for pt goal and likely disposition when DC time comes around.

#3 requires that you write up DC orders and write a discharge note. All of this takes time, which will vary from pt to pt as they are dependent on complexity.

I'm sure there's some other info I'm forgetting but I'll let others chime in.

Just remember that YOU WILL GENERATE REVENUE for the practice. Make sure they compensate you fairly and don't be timid in reminding them that without you THEY ARE LOSING OUT on potential revenue.

Best of luck.