How to get paid for taking call
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Physicians increasingly are asking hospitals for remuneration for emergency department call, and more hospitals are willing to provide it.
Getting paid for taking call, however, can be a delicate business. Some institutions don't pay anything. Some pay only for "extra" call. Some pay for any and all call. Rates can vary based on specialty. Pay for taking call even can go into a tax-deferred retirement account. And hospitals that do pay have to be especially mindful of federal anti-kickback statutes that prevent paying for referrals.
"You do not want to get into a situation where you are going to be violating regulations, and you don't want to push the hospital into using your competitor or going out and hiring physicians just for call," said Jeffrey Milburn, a Medical Group Management Assn. consultant.
Experts say that before approaching an institution, physicians should research the types of arrangements in a particular market for a physician's specialty. These can vary widely, and this information is available from some medical societies and practice consultants.
For example, the Medical Directorship and On-Call Compensation Survey: 2010 Report Based on 2009 Data, released in April by MGMA, found that family physicians earned an average of about $100 per day in traditional stipend arrangements, but neurosurgeons were paid $1,671. Payments for holiday and weekend coverage ranged from $588 per day for family physicians to $3,000 for general surgeons.
Specialists are the most likely to be paid for taking call. Payments for primary care physicians are possible, although less common, because so many hospitals use hospitalists. According to the MGMA report, 56.1% of primary care physicians received some form of additional compensation for on-call coverage, as opposed to 72.5% of surgical specialists.
"This is so situational and regional. In some places it is fairly common to get paid for call, but some hospitals are still resisting," Milburn said. "It's difficult to have a one-size-fits-all [approach]. The first question I would ask is, 'What is happening in your locality?' "
Payment might be affected by the number of physicians in a particular specialty who share the call burden. Those sharing it with only one other colleague tend to be paid more than those splitting it with five. Whether a physician has to stay at the hospital or within a certain distance also can affect payment.
Once physicians are ready with local market information, experts suggest they approach institutions with a focus on how providing compensation for call better serves the community and patients. "Be prepared to tell the hospital what you can do for them," Milburn said.
Experts cautioned, however, that any payment for call coverage must be at fair market value to reduce the risk of running afoul of various anti-kickback regulations that prohibit hospitals from paying for referrals.
"Physicians have to understand that there are some constraints that hospitals have to abide by that really restrict the amount that hospitals can pay to physicians," said Joshua Halverson, a principal with ECG Management Consultants in St. Louis.
The Health and Human Services Office of Inspector General has published several opinions stating that hospitals can pay for on-call coverage if necessary to sustain services. Payments should be determined in advance. Call coverage should be divided equally within specialties, and physicians should provide a minimum amount of uncompensated care.
Follow-up services must be provided, and any setup needs to avoid physicians being paid twice for the same work, such as if a hospital pays for a physician's services, and the patient pays the practice directly.
Experts also advocate that any contract for on-call coverage be considered in context with other deals with the hospital, such as those for joint ventures or medical directorships, to ensure that the combination does not violate regulations.
Also, physicians don't have to suggest merely a flat stipend for covering call. Consultants said more creative arrangements might work.
For example, some physicians receive an "activation fee" every time they are called in, which is in addition to the charge for being available. Others get paid only for being on call in excess of a certain number of days per month, otherwise known as "extra" call. Still others have productivity arrangements that mean they get paid by the hospital for some or all of the work they perform.
This can work particularly well if being on call means providing care for large numbers of indigent patients, experts said.
Another option for pay is the tax-deferred retirement account, which was described at the "Building Long-Term Relationships With Physicians Who Take Call" seminar held March 24 at the American College of Healthcare Executives meeting in Chicago. It is modeled on compensation plans often offered to high-level executives and usually takes the form of a contract that requires a physician to take call over a number of years.
"In private practice, you don't really have the opportunity to put money away for yourself for retirement," said Michael Hogue, MD, one of the presenters and a senior consultant with Integrated Health Care Strategies in Minneapolis. "This type of arrangement can provide tremendous advantages."