Why do anesthesiologists make more than CRNAs?

allnurses Guide · Oct 22, 2013

Is it because they can bill multiple cases at the same time within ACT practices?
I've heard that reimbursement is the same for CRNAs or MDAs providing the anesthesia, is this true? In other words, if an independent CRNA performs the same case as an independent MDA, will they be reimbursed the same amount?
Thanks!
P.S. This is not a should MDAs/CRNAs make more than each other etc. etc. question. This is specifically about current practices with billing and cost of anesthesia.

Yes and No. MDAs and CRNAs can receive the same in billing. Medicare will usually pay the same for services rendered by either provider, but there are some insurance carriers that will pay MDAs more for the same services rendered.

MDAs can usually become partners in a combined anesthesia group where CRNAs cannot, and becoming a partner can considerably increase MDA salary. MDAs can also bill up to 4 cases simultaneously when "medical supervising", thus allowing them to bill up to 200% what they could make doing their own cases. Although, it is virtually impossible for an MDA to meet the TEFRA requirements while "medically supervising" 4 cases at one time.

jwk · Oct 22, 2013

Yes and No. MDAs and CRNAs can receive the same in billing. Medicare will usually pay the same for services rendered by either provider, but there are some insurance carriers that will pay MDAs more for the same services rendered.
MDAs can usually become partners in a combined anesthesia group where CRNAs cannot, and becoming a partner can considerably increase MDA salary. MDAs can also bill up to 4 cases simultaneously when "medical supervising", thus allowing them to bill up to 200% what they could make doing their own cases. Although, it is virtually impossible for an MDA to meet the TEFRA requirements while "medically supervising" 4 cases at one time.

The TEFRA requirements you're referring to are for medical "direction", not medical "supervision". Those two terms are not synonymous in this setting (you of course know this I'm sure). And although you may not think it's possible, it is far from impossible to meet those requirements at 1:4. We do it every day as do most groups. Sure, I'm sure you can pull out a case report or two or a study or two that you think "proves" that you're correct, but those of us in the real world know better.

As far as MD's making more - there are a number of explanations for this. MD's frequently are doing more advanced / higher reimbursement procedures that bring far more relative value units into play. You generally don't find solo CRNA's doing liver transplants, cardiac valve replacements and other open-heart procedures, etc. Modifiers and additional charges for things like TEE are generally out of the purview of a CRNA. Chronic pain management, particularly those cases involving implanted devices, are frequently out of the CRNA bag of tricks, although yes, I know there are exceptions.

allnurses Guide · Oct 22, 2013

The TEFRA requirements you're referring to are for medical "direction", not medical "supervision". Those two terms are not synonymous in this setting (you of course know this I'm sure). And although you may not think it's possible, it is far from impossible to meet those requirements at 1:4. We do it every day as do most groups. Sure, I'm sure you can pull out a case report or two or a study or two that you think "proves" that you're correct, but those of us in the real world know better.
As far as MD's making more - there are a number of explanations for this. MD's frequently are doing more advanced / higher reimbursement procedures that bring far more relative value units into play. You generally don't find solo CRNA's doing liver transplants, cardiac valve replacements and other open-heart procedures, etc. Modifiers and additional charges for things like TEE are generally out of the purview of a CRNA. Chronic pain management, particularly those cases involving implanted devices, are frequently out of the CRNA bag of tricks, although yes, I know there are exceptions.

I want to see the person that can be in 4 places simultaneously. This must be why CMS has been auditing and bringing cases against several ACT practices lately.

Yes, I live in the real world, but apparently you live in place that allows people to be in several places at one time.

So, when CRNAs do all those extra revenue practices that you mention they should be reimbursed at a higher rate to by your reasoning. I am glad to hear an AA advocating for CRNAs to make higher wages...

loveanesthesia · Oct 23, 2013

A type of practice that is becoming more common is a group of anesthesiologists will employ several CRNAs. The CRNAs are practicing and billing as an independent CRNA. The group pays the CRNA a salary and keeps the difference between what the group collects in billing and the CRNA salary. It may not sound good for the CRNA but it is job security. The anesthesiologists who are doing this are making a profit on each CRNA they employ, surgeon/patient satisfaction is high, and they don't have to worry about billing fraud with medical direction (I worked in a medically directed practice and even with the best of intentions you either have to hold up cases, or violate the rules on a regular basis). It is creating more CRNA positions.

Mully · Oct 23, 2013

loveanesthesia - so then are the anesthesiologists then doing their own cases as well? Each practitioner practicing anesthesia alongside each other?

Thank you wtb and jwk for your responses. So it seems to sum it up, MDAs have significantly higher income potential based on difficulty modifiers and multiple procedure billing due to medical "direction". That's what I was wondering!

jwk · Oct 23, 2013

I want to see the person that can be in 4 places simultaneously. This must be why CMS has been auditing and bringing cases against several ACT practices lately.

This is a prime example of a misleading statement by a CRNA, the kind used every day in their fight against the ASA. You know very well that CMS does not require that the MD "be in 4 places simultaneously". What the law says is that they can't medically direct more than 4 cases at one time. Quite a different reality than what you're trying to sell to the uninitiated and uninformed.

Wow - "auditing and bringing cases against several ACT practices". Out of how many hundreds or thousands of anesthesia practices nationwide? And please, you don't think that billing fraud occurs in solo CRNA or CRNA-only group practices as well?

jwk · Oct 23, 2013

A type of practice that is becoming more common is a group of anesthesiologists will employ several CRNAs. The CRNAs are practicing and billing as an independent CRNA. The group pays the CRNA a salary and keeps the difference between what the group collects in billing and the CRNA salary. It may not sound good for the CRNA but it is job security. The anesthesiologists who are doing this are making a profit on each CRNA they employ, surgeon/patient satisfaction is high, and they don't have to worry about billing fraud with medical direction (I worked in a medically directed practice and even with the best of intentions you either have to hold up cases, or violate the rules on a regular basis). It is creating more CRNA positions.

I think you're trying to describe what is commonly known as a "collaborative" practice, and those are popping up here and there. However, in a collaborative practice, CRNA's and MD's don't have the same employer. If a CRNA assigns their billing rights to the group to collect AND is an employee of the group, that's not really a collaborative practice since an employer / employee relationship exists which means by definition they're not "independent". Or perhaps this group you describe is billing as medical supervision rather than medical direction.

I've worked in ACT practices for more than 30 years, and have been in what is now defined as a "medically directed" practice for more than 20. We make it work and we follow all 7 specifications of the TEFRA law. Does a surgeon occasionally have to wait a couple minutes? Sure. We wait on them all the time, so that's really not a valid factor. Perhaps the difference is that our anesthesiologists aren't consumed with non-clinical activities like crosswords and stock-picking which is the stereotypical anesthesiologist mantra of the stereotypical "we should be independent" CRNA. Our docs are actually working - covering their assigned rooms, present for induction and emergence, doing pre-ops, blocks, etc. On a typical OB shift, they'll put in 15 or more epidurals. Not a lot of down time.

manusko · Oct 23, 2013

This is a prime example of a misleading statement by a CRNA, the kind used every day in their fight against the ASA. You know very well that CMS does not require that the MD "be in 4 places simultaneously". What the law says is that they can't medically direct more than 4 cases at one time. Quite a different reality than what you're trying to sell to the uninitiated and uninformed.
Wow - "auditing and bringing cases against several ACT practices". Out of how many hundreds or thousands of anesthesia practices nationwide? And please, you don't think that billing fraud occurs in solo CRNA or CRNA-only group practices as well?

Where ever you find money you can very well find fraud. I don't think it's exclusive to any one group.

Now some practices are being very cautious with 4:1 and are actually already doing 3:1 to avoid future problems with these supervision/direction roles.

jwk · Oct 23, 2013

Where ever you find money you can very well find fraud. I don't think it's exclusive to any one group.
Now some practices are being very cautious with 4:1 and are actually already doing 3:1 to avoid future problems with these supervision/direction roles.

Agree on both points - we prefer 3:1 whenever possible.

allnurses Guide · Oct 24, 2013

The studies suggest no more than 2:1 d/t difficulties meeting TEFRA requirements.

The sad thing is all that is doing is increasing is overall costs without any benefit to patients or hospitals. There doesn't need to be supervision of CRNAs in the first place and if all the MDAs and CRNAs ran there own rooms there would be no shortage of anesthesia providers.

mindlor · Oct 24, 2013

Ummmmm asking why a medical doctor makes more than an advanced practice nurse? How many years does it take to become an anesthesiologist? If a CRNA wants to get paid like an anesthesiologist then they should head on off to med school eh?