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Only doctor left in practice. How do I negotiate with admin?

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  • Only doctor left in practice. How do I negotiate with admin?

    Hi everyone,

    This is my first post and I am hoping to get some advice.

    I recently started my first job post residency in an outpatient primary care clinic associated with a large hospital system. I have been in the position for less than a year. One of my colleagues retired last week and the only other provider in the clinic is on extended leave. This leaves me as the only physician in the clinic for next several months. Currently I am working M-F and seeing ~ 15 patients within my 8 hour day. On a given day, more than half my patients are elderly/geriatric, with multiple medical co-morbidities and they are all new to me.

    I am on an initial guaranteed salary. I approached the admin two weeks ago asking for 4 hours of admin time/week and they refused, saying that I am not seeing enough patients. Additionally, I am now receiving various forms & refill requests from patients of my former colleague, all of whom I have never seen before, which is adding extra work.
    1. How do I negotiate getting the 4 hours admin time per week that is mentioned in my contract but not written as guaranteed?
    2. Is it possible to get off guaranteed salary and work fewer days to keep from getting burned out, even though my current contract states that my first two years are guaranteed salary?
    3. How is the refill requests/various forms of patients of former colleague typically handled? I don't feel comfortable refilling medications without seeing them and I have been asking patients to make a visit with me to get refills on their chronic medications. Since I have never been in this situation before, I want to know how do other practices typically handle these?
    Thank you in advance.

  • #2
    I have been doing this for years. Get used to seeing more patients. I usually see 15 patients before lunch.

    as far as the rest, learn to delegate , you should not have to do refills yourself and the most you should have to do is put a scribble on the bottom of the form. If the for is not completely filled out , I send it back. Most of all , if you don’t feel comfortable doing something, then don’t. Tell them to make an appointment. If you trust your previously colleague, I would refill most regular meds for up to 3 months or what ever you would typically do for your own patients.

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    • #3
      I'm not in outpatient primary care but aren't they right that 15 isn't enough patients for an 8 hour day?

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      • #4
        I’m not primary care but I agree with admin that you probably aren’t seeing enough people. 15 patients in 8 hours seems pretty light, to put it nicely. That said, in my opinion, you should have no obligation to fill out forms and refills for patients you’ve never seen. Have those folks make an appt with you.

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        • #5
          It's hard to negotiate a schedule if the ramifications of seeing less patients don't affect you. You could ask to be 100% wRVU based but if you do this I think you will find you wont want to do 4hrs admin time...

          It's ok you don't see a ton of patients thats why you have a guarantee while you build your patient panel, speed will come with time...

          What you could do is look and see if there is any language about call in your contract. Since now you are on call 100% time M-F you could argue you need to be payed extra or no longer take any calls/requests for other patients... Though if this person is coming back from leave and you want them to cover your vacations you may want to walk that line carefully

          If the work load is indeed more than you bargained for you can simply make time slots or patients of the day a long appointment. I.E a 30 min pt gets booked as 60min at end of the day. This plays the admin game. Admin sees your schedule is full but you have extra time...

          Can only pick 2: Time with patients, good documentation, large patient volume.

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          • #6
            Originally posted by Otolith View Post
            It's hard to negotiate a schedule if the ramifications of seeing less patients don't affect you. You could ask to be 100% wRVU based but if you do this I think you will find you wont want to do 4hrs admin time...

            It's ok you don't see a ton of patients thats why you have a guarantee while you build your patient panel, speed will come with time...

            What you could do is look and see if there is any language about call in your contract. Since now you are on call 100% time M-F you could argue you need to be payed extra or no longer take any calls/requests for other patients... Though if this person is coming back from leave and you want them to cover your vacations you may want to walk that line carefully

            If the work load is indeed more than you bargained for you can simply make time slots or patients of the day a long appointment. I.E a 30 min pt gets booked as 60min at end of the day. This plays the admin game. Admin sees your schedule is full but you have extra time...

            Can only pick 2: Time with patients, good documentation, large patient volume.
            The iron triangle of patient care. I like it!

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            • #7
              i think the easy solution here is that you cannot do uncompensated work for your colleagues with no plan from admin.

              the way you lose this battle is if you send a 3 page email to admin detailing your frustration and dripping w/ anger. a better way to handle it is just to be less communicative about it but very clear: sorry i cannot fill out that form. if you are pressed for details, you don't have to give them.

              i agree with what others have said you are seeing a very light schedule and that is going to make it very hard to negotiate anything. at 15 o/p visits/day you might not even be covering your overhead, if not they aren't going to give you anything extra.

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              • #8
                All forms of patients that you had never met need an office visit to meet them and fill out that form. I rarely fill out forms even from my own patients without an office visit. Refills the same. This will reduce your uncompensated work and increase your office visit numbers.

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                • #9
                  Similar thing happened to me but the other provider went on leave for 6 months. It was actually beneficial to me given I was seeing the other providers patients which increased my wRVUs and some of those patients remained with me. Agree don't refill or fill out forms without appt unless it's a necessary medication, anything you don't feel comfortable just have them follow up.

                  Don't get off guarantee otherwise if your wRVUs presently is less than projected you'll take a cut in pay.

                  Make sure you are billing appropriately based on new EM coding given you are seeing complex patients, 15 complex patients can get you to easily above 20 wRVUs a day

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                  • #10
                    At 15 pts/day, it should not be too hard to squeeze them into 7 hours 4 days/week.
                    Voila! There’s your 4 hours of admin time.

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                    • #11
                      "This is my first post and I am hoping to get some advice.
                      I recently started my first job post residency in an outpatient primary care clinic associated with a large hospital system. I have been in the position for less than a year."

                      I understand the frustrations. But you also need to be realistic. Transition to attending takes time. Your volumes will increase as you make adjustments and hopefully you on your own or with coaching make adjustments and get comfortable and meet the expectations.
                      What was missing was the expectations for patient volumes under your current contract as a new attending. Very difficult to negotiate an increase out of "thin air". The problem is the additional work on top of the "expected" work. The admin has not clarified the "expected" patient volumes without the additional work. That is not unexpected during the first year of a two year contract. I would suggest that solidifying the "expectations" before you ask for compensation for the additional work.
                      The baseline is the question mark. From their point of view, the additional work might be viewed as only making up for lower than expected volumes.

                      Purely a numbers game in knowing your worth.

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                      • #12
                        This is a fun one. I am with you. New primary care attending (IM). Been in practice for 2 years.

                        First issue (your former retired colleague), remember that you do not have a patient-physician relationship with these patient if you have never seen them or provided a refill. Once you provide a refill, you do have a patient-physician relationship. It is not your responsibility to provide refills without seeing your former colleague's patients. It is your health system's job to figure out how to maintain them within their system. I personally do no provide refills unless I have seen the patient with the exception of covering for one of my colleagues. I will provide enough medication until they follow up with their PCP if I am covering while they are on vacation.

                        Next issue is coverage of your current colleague. Did you agree to cover for them while he/she is out? If not, let admin figure out that stuff. If I was taking an extended leave of absence, I would monitor my messages and inbox once a week for my patients for refills, etc. No way would I burden my colleagues like that.

                        Patient load: will get easier as your learn your patients. It does suck when everyone is new and complicated. Bill appropriately. Sounds like most are 99214 visits. You will be in the 20 to 25 range in a short amount of time. Also do not handle every problem at every visit.

                        Contract: No one here has seen your contract. If you have allotted time specifically designated in your contract, you have a few choices: 1. Block off your allotted time per your contract 2. Meet with an attorney and determine if your hospital system has breached your contract 3. Continue doing what you are currently doing.

                        Remember that your health and wellbeing are important. Also remember that you bring in money for the healthcare system. You have both tangible and intangible value. If your current employer does not seem to grasp that, there are other jobs out there.

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                        • #13
                          Welcome OP.

                          Geriatrics is a different monster. With the 15/day 8 hours; you should be coding Level 5 for the majority of those visits at that pace let alone extended time drops. If you're not - you're not going to make the RVUs that admin is anticipating.

                          You need to spell out a very specific issue since your hire: -- clinician coverage/turnover. You're covering for 3 clinicians AND doing the daily work. That is not okay without appropriate compensation/adjustment.

                          Action you can take:
                          1. Spell this out in specific terms. Forms, refills, non-F2F work not directly related to your patients you are assigned -- will not be done. Admin will need to either get Locums or pay you for that coverage.

                          2. Code adequately for the 15patients a day. This is probably the primary reason admin thinks 15 is light. They are most likely watch the RVUs. If not - ask them specifically what metrics they are using assess proper amount of patient load.
                          Last edited by StarTrekDoc; 07-06-2021, 12:33 PM.

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                          • #14
                            StarTrekDoc- I see a ton of geriatrics and I code 99215’s very infrequently. Are you suggesting 15/day geriatrics = code for time and get 99215’s? Or that most geriatric follow ups are 99215’s? I will admit that our compliance person is tremendously conservative re 99215, so my feel is that I do a lot of 99214.999’s that don’t tip into 99215 MDM. (Example: address 5 issues and associated medication refills/labs).

                            Now, uncontrolled dm2, med change; uncontrolled Htn, med change, both needing labs was posited as a 99215 somewhere that I read. However this didn’t seem to meet guidelines to my understanding.

                            Under-coding and giving away care are classic common problems - we aren’t taught to code and we don’t want to inconvenience patients or make them pay. Otoh, I feel very very good that I was able to do a quick 10 minute video visit today to bill a 99215 for all the work around that to get a lady admitted to snf.

                            regarding forms, I always tell patients that I want to see them to ensure everything is done accurately and correctly the first time and at the time of the appointment- you get a lot more buyin that way.

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                            • #15
                              If you bill by time using new EM coding >40 minutes spent is a level 5 follow up and that includes charting time!

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