Is it actually worth it to become an RNFA?

Fun2, BSN, RN · Aug 30, 2008

I would love it, but where I work, it wouldn't be beneficial.

I work at a teaching hospital. Therefore, the residents close, etc.

IPrepU · Sep 1, 2008

Good question. I am in the process of RNFA right now. My first response is that I should have done it sooner. I am not working full-time in any one hospital right now so I am having a very hard time getting into ORs to get my clinical time in. Even though the OR staffs know me I still have to go through the Admin. staff who don't.

Plus, I am seeing alot more PA's coming into the OR. Unfortunately very few have had any OR training, which (in my opinion) should be mandatory.

I think depending on which state you are in, RNFA can be very lucrative. I recently worked with a travel nurse from New York who is an RNFA. She told me that she made anywhere from $400-$600 for a simple Lap Chole. Now, if you work with a surgeon who can do a Lap Chole in an hour (or less), then that is definetely Good $$.

core0 · Sep 2, 2008

Good question. I am in the process of RNFA right now. My first response is that I should have done it sooner. I am not working full-time in any one hospital right now so I am having a very hard time getting into ORs to get my clinical time in. Even though the OR staffs know me I still have to go through the Admin. staff who don't.
Plus, I am seeing alot more PA's coming into the OR. Unfortunately very few have had any OR training, which (in my opinion) should be mandatory.

Actually as of 2007 its mandatory for all PA students to have OR time. So this should eventually be a self correcting problem.

I think depending on which state you are in, RNFA can be very lucrative. I recently worked with a travel nurse from New York who is an RNFA. She told me that she made anywhere from $400-$600 for a simple Lap Chole. Now, if you work with a surgeon who can do a Lap Chole in an hour (or less), then that is definetely Good $$.

The problem is that its a lot more complicated than that. $400 for an assist fee for a lap chole means the physician fee is more than $2000 which would be pretty rare. Medicare will reimburse the surgeon between $6-700 for a lap chole. This would translate to a first assist fee (best case scenario) of between $120-140. Most insurance companies pay some percentage above Medicare but not that much.

The other issue is how you get cases. Either the physician says get someone to help me or the surgeons scheduler gets someone to help. In either case you have to develop a relationship with either the hospital front desk or the physician (realistically their scheduler). This determines how much work you get. If you get reasonably busy with a bunch of different surgeons then you run the risk of having to tell someone that you can't help and they stop using you. Then you have to go make up with the scheduler. Kind of like dating. Depending on the surgeon they may also want the RNFA to cover cases that don't reimburse (Medicare and no-pay - I mean "self-insured"). They still need the help. One of the trade offs of getting the business is that you help them no matter what the issue. Some surgeons are nice and will just have the scrub help on non-reimburseable cases but that just makes the case go longer making it even less profitable. I worked at a couple of hospitals that paid the RNFAs and SAs some token amount for Medicare/self pay - usually $10 per hour skin to skin.

The other extreme is where you work for the hospital. I know of some hospitals that designate their techs or RNs as assists and pay them $1-2 hour more than their regular pay. Others hire RNFAs and then try to bill for them. Pay is usually above RN pay but not a whole lot (see above).

The middle ground is to work for a group. The groups are contacted by either the physician or the hospital and then schedule an assist. The advantage is that their is someone to cover when their are more than two cases going on at once. Also if you take a vacation all your business doesn't dry up. They also usually handle billing. The disadvantage is that some of these groups have a bad reputation and you get associated with that reputation. Also you make less money. Usually you get either a percentage of the collections or you get a flat hourly rate.

Lets say you decide to go for the big money and go out on your own. You have a good relationship with a bunch of surgeons who call on you regularly. The surgeon is relatively quick and they set you up with three lap choles between 8 and noon. The first starts on time and you get done at 9. Then your second case gets bumped for an emergency D&C. The surgeon goes off to round while you sit in the lounge and watch CNN. The second case finally starts at 10. You finish at 11. However turnover takes an hour because they have to Steris the scope and then they lose the H&P:smokin:. You finally start at 1230. Now you have a problem because you have to help another surgeon at 1. You call them and they say no problem we'll find someone else. You finish at 2 (lots of adhesions). You've been there a total of six hours.

Now comes time to get paid. You have a good biller and you have a good relationship with the surgeons biller. You get a copy of the surgeons bill and submit the same CPT and ICD-9 codes. Then you wait. The surgeons reimbursement for this is $800, $900 and $1000 dollars. So you would expect around $540. However you find out that insurance A only reimburses first assist at 14%. Company B reimburses you at 20% but initially rejects your billing requiring you to re submit an appeal which may eventually be paid. You find out company C does not reimburse first assist on Lap Choles since the first assist is unnecessary. You finally get a check from company A for $112. That takes 30 days. You may get another $180 dollars in another 60 days from company B. So your total take for six hours work is $292 or a little less than $50 per hour. Out of that the billing company will take a percentage and you have to pay all your expenses. Also thats all you did all day. No opportunities to work extra since you missed your other case. Also if the surgeons don't work (or all work at the same time) then you don't work.

There are RNFAs (and SAs) out there making six figures but they are pretty rare. Most are probably making the same or less than they are making as an RN. For that matter why would someone that is making $400 per case take a travel assignment (for a hint see above).

Because of the economics both the RNFA and the SA are a dying breed (in my opinion). As a greater percentage of the country transfers to Medicare this will become more apparent. They will stay on in some areas simply because someone (usually the hospital) is willing to accomodate the surgeons or there are simply no NPPs available in that area. Overall, though a more secure route would be to get an RNFA in conjunction or as a prelude to a NP degree (or PA:D).

Just my opinion having watched this market for more than 10 years.

David Carpenter, PA-C

Karey73 · Jun 25, 2011

I would say it really depends what state you live in and what type of relationships you have with the providers and hospital. I am an RNFA and do quite well in Colorado. My experience was on an open heart team, but the call became too much so I left and went out on my own. I still work prn for the 2 hospitals in town which is nice because I can always circulate or scrub if I am slow on cases. Both my hospitals pay me way more than a nominal rate to assist on cases that I cannot bill for. I independently bill insured cases. You just have to be carefful not to double dip (being paid by the hospital as well as billing the pts insurance). I think one of the big reasons for my success is that I don't sit in the lounge and watch CNN while I wait for a case. I get in there and turn over the room, help get open and ready. At the end of the case, I send the tech on a break and help clean up. Hospitals really appreciate that therefore they call me before others. I approach every case with the attitude, "how can I make this case better for the patient and easier for the surgeon?" It has worked well for me and I really enjoy the new freedom and control I have over my schedule. I would definitely say becoming an RNFA is worth it. In the meantime really work on creating some great relationships with your hospitals admin and the physicians.

stoneykr · Sep 30, 2011

My question is for David Carpenter PA-C. To become a PA is my long term goal. I was thinking of getting and associates in Radiation Therapy or Diagnostic Cardiac Ultrasound Technician to get my foot in the door with better patient contact than just as an EMT-I then finish my Biology BS part time then apply to various PA schools. I noticed the RNFA track and was wondering if that option should be seriously considered by me. I have a background with firefighting and EMS but am looking for a career change. After much deliberation I have found that without a doubt, 100% I am all for PA over MD/DO. Any advice would be beneficial.

Thank you.

stoneykr · Sep 30, 2011

My question is for David Carpenter PA-C. To become a PA is my long term goal. I was thinking of getting and associates in Radiation Therapy or Diagnostic Cardiac Ultrasound Technician to get my foot in the door with better patient contact than just as an EMT-I then finish my Biology BS part time then apply to various PA schools. I noticed the RNFA track and was wondering if that option should be seriously considered by me. I have a background with firefighting and EMS but am looking for a career change. After much deliberation I have found that without a doubt, 100% I am all for PA over MD/DO. Any advice would be beneficial.

Thank you.

rjorrn · Aug 9, 2012

I would say it really depends what state you live in and what type of relationships you have with the providers and hospital. I am an RNFA and do quite well in Colorado. My experience was on an open heart team, but the call became too much so I left and went out on my own. I still work prn for the 2 hospitals in town which is nice because I can always circulate or scrub if I am slow on cases. Both my hospitals pay me way more than a nominal rate to assist on cases that I cannot bill for. I independently bill insured cases. You just have to be carefful not to double dip (being paid by the hospital as well as billing the pts insurance). I think one of the big reasons for my success is that I don't sit in the lounge and watch CNN while I wait for a case. I get in there and turn over the room, help get open and ready. At the end of the case, I send the tech on a break and help clean up. Hospitals really appreciate that therefore they call me before others. I approach every case with the attitude, "how can I make this case better for the patient and easier for the surgeon?" It has worked well for me and I really enjoy the new freedom and control I have over my schedule. I would definitely say becoming an RNFA is worth it. In the meantime really work on creating some great relationships with your hospitals admin and the physicians.

I am a new grad Associates Degree RN with 20 years of surgical experience as a CST/ Certified Surgical First Assist. I too am interested in becoming an RNFA and have been offered a job in a Georgia OR as a circulating/scrub/assistant nurse.

As a condition of employent on the CVOR staff at the trauma center I was employed at 15 years ago in Ohio, I completed an RNFA course through a local university. At that time CST's were not elligible to sit for certification so I had to take it later in another state (Florida). I have been first assisting for more than 12 years in specialties ranging from Cardiac to Orthopedics. Does anyone know if there is any way I can "challenge" the test, or shorten the process of obtaining my RNFA at this point?

HollywoodDiva · Aug 11, 2012

I don't believe you can challenge that at all because they do require you to have x amount of experience as an OR nurse.

LoopsRN2 · Aug 25, 2012

Actually as of 2007 its mandatory for all PA students to have OR time. So this should eventually be a self correcting problem.
The problem is that its a lot more complicated than that. $400 for an assist fee for a lap chole means the physician fee is more than $2000 which would be pretty rare. Medicare will reimburse the surgeon between $6-700 for a lap chole. This would translate to a first assist fee (best case scenario) of between $120-140. Most insurance companies pay some percentage above Medicare but not that much.
The other issue is how you get cases. Either the physician says get someone to help me or the surgeons scheduler gets someone to help. In either case you have to develop a relationship with either the hospital front desk or the physician (realistically their scheduler). This determines how much work you get. If you get reasonably busy with a bunch of different surgeons then you run the risk of having to tell someone that you can't help and they stop using you. Then you have to go make up with the scheduler. Kind of like dating. Depending on the surgeon they may also want the RNFA to cover cases that don't reimburse (Medicare and no-pay - I mean "self-insured"). They still need the help. One of the trade offs of getting the business is that you help them no matter what the issue. Some surgeons are nice and will just have the scrub help on non-reimburseable cases but that just makes the case go longer making it even less profitable. I worked at a couple of hospitals that paid the RNFAs and SAs some token amount for Medicare/self pay - usually $10 per hour skin to skin.
The other extreme is where you work for the hospital. I know of some hospitals that designate their techs or RNs as assists and pay them $1-2 hour more than their regular pay. Others hire RNFAs and then try to bill for them. Pay is usually above RN pay but not a whole lot (see above).
The middle ground is to work for a group. The groups are contacted by either the physician or the hospital and then schedule an assist. The advantage is that their is someone to cover when their are more than two cases going on at once. Also if you take a vacation all your business doesn't dry up. They also usually handle billing. The disadvantage is that some of these groups have a bad reputation and you get associated with that reputation. Also you make less money. Usually you get either a percentage of the collections or you get a flat hourly rate.
Lets say you decide to go for the big money and go out on your own. You have a good relationship with a bunch of surgeons who call on you regularly. The surgeon is relatively quick and they set you up with three lap choles between 8 and noon. The first starts on time and you get done at 9. Then your second case gets bumped for an emergency D&C. The surgeon goes off to round while you sit in the lounge and watch CNN. The second case finally starts at 10. You finish at 11. However turnover takes an hour because they have to Steris the scope and then they lose the H&P:smokin:. You finally start at 1230. Now you have a problem because you have to help another surgeon at 1. You call them and they say no problem we'll find someone else. You finish at 2 (lots of adhesions). You've been there a total of six hours.
Now comes time to get paid. You have a good biller and you have a good relationship with the surgeons biller. You get a copy of the surgeons bill and submit the same CPT and ICD-9 codes. Then you wait. The surgeons reimbursement for this is $800, $900 and $1000 dollars. So you would expect around $540. However you find out that insurance A only reimburses first assist at 14%. Company B reimburses you at 20% but initially rejects your billing requiring you to re submit an appeal which may eventually be paid. You find out company C does not reimburse first assist on Lap Choles since the first assist is unnecessary. You finally get a check from company A for $112. That takes 30 days. You may get another $180 dollars in another 60 days from company B. So your total take for six hours work is $292 or a little less than $50 per hour. Out of that the billing company will take a percentage and you have to pay all your expenses. Also thats all you did all day. No opportunities to work extra since you missed your other case. Also if the surgeons don't work (or all work at the same time) then you don't work.
There are RNFAs (and SAs) out there making six figures but they are pretty rare. Most are probably making the same or less than they are making as an RN. For that matter why would someone that is making $400 per case take a travel assignment (for a hint see above).
Because of the economics both the RNFA and the SA are a dying breed (in my opinion). As a greater percentage of the country transfers to Medicare this will become more apparent. They will stay on in some areas simply because someone (usually the hospital) is willing to accomodate the surgeons or there are simply no NPPs available in that area. Overall, though a more secure route would be to get an RNFA in conjunction or as a prelude to a NP degree (or PA:D).
Just my opinion having watched this market for more than 10 years.
David Carpenter, PA-C

I have been working as a first assist since 1998, RN/CSA and although this reply is from 2008 I have to say this is one of the most honest and well written responses regarding the future of the CSA/CSFA/RNFA. All of this still applies 4 years later.

rncoco · Oct 15, 2012

I too would also like to become an RNFA. However, after reading this I kinda got discouraged. I am an RN in australia and have a post grad diploma in perioperative nursing. I wish to become an RNFA when I move to new york, however seeing that I wont have many connections there I might have difficulty getting a job. I am very interested in the work though. I like the idea of assisting surgeons because I like to "get in there" and not just circulate. I have a fair it of experience in scrubbing too because here at our hospital we do both