Side Gig: Supplementing Income With Skilled Nursing Facilities

Picking up extra shifts in a subacute care facility sounds like a wonderful idea. Almost no overhead is involved for the physician, especially since most doctors already have a laptop and a malpractice policy. It seems like a natural progression that almost every hospitalist or primary care physician goes through, telling yourself that you can make extra money doing subacute care. The patients are often insured, grateful for the care given, chronically sick but often not acutely ill. Sounds easy enough right?

After all, if a patient does get acutely ill you send them to the hospital.

I enjoy my time doing skilled nursing work and assisted living work. However, most doctors seem to be under the impression that the work is easy. Although the acuity of illness is not as severe compared to the hospital, the work is definitely not easy. It’s not unusual to spend many hours involved in working at these facilities while being on call 24/7 for their needs.


Subacute Care or Post Acute Care

Lets define the two real quick:

Post acute care is a term for any care delivered to patients after leaving a hospital or an acute care facility. This can range from skilled nursing facilities to home health services or palliative care services. I am defining subacute care as care delivered to inpatients in a non-home, non-hospital setting. Often times this will be at a skilled nursing facility.

My dog Duke out on the farm.


How Much Money Is In Subacute Care


The number of beds can range wildly from facility to facility. Most facilities that I’ve worked in have anywhere from about 60 to 120 beds.

The CPT codes billed for follow up visits at a skilled nursing facility range from 99307 through 99310. The average income per follow up based on the range of CPT payout is about $80.

This may sound like a decent amount of money but many of these patients can not be seen more than once to at most twice a week.  Long term, patients are seen monthly to once every three months.

Lets assume that every single patient is receiving skilled services and that this physician is seeing all 100 people in the facility. If the physician sees every patient once a week they will bill for about $8,000 worth of services. *Remember these are back of the napkin kind of rough numbers with no admits or discharges*

Seems great but you will most likely not be the only group or physician in the facility seeing patients. Most facilities will have at least 2 different doctors or groups seeing patients. As a new doctor in the facility, odds are you will start with zero patients and have to build a census from there. This can take many months to years to do.

Did I mention that you also won’t be getting paid to be on call or to cross cover your patients at 2am from home?


How To Get Into Subacute Care

Lets assume that you still might be interested in making extra money in subacute care. Follow these steps to get into subacute care:

  1. First step is to open a legal business entity, most likely a PLLC. Then, call your malpractice insurance provider and make sure that your current malpractice coverage will cover subacute work. If not, your coverage can be expand to include this type of care.
  2. Contact insurance companies to get credentialed as in network with payers, Medicare will be very important for you if it wasn’t before. You need to be in network for each location that you work potentially depending on your state rules.
  3. Visit skilled nursing facilities or assisted living facilities and introduce yourself to the individuals in charge. See if they are willing to have you rotate through their facility and start seeing patients.
  4. Familiarize yourself with the rules of seeing patients at a skilled nursing facility.
  5. Find an EMR you like and obtain a license to use it. You can literally find more than 100 EMR’s to use.
  6. Figure out coverage when you plan on taking vacations or who is going to answer phones at 2am.
  7. Meet with social workers of the local hospitals and introduce yourself to them since quite a few patients will be admitted to subacute care from acute care.
  8. Fill out the credentialing paperwork
  9. Once you’re approved, start seeing patients once you are in network with insurance payers.


It Often Sounds Better Than It Is

Life in subacute care sounds possibly rosy in this post up until now. You can round on your own terms, the patients are not sick enough to be in the hospital, and the patients are often very appreciative for your help. These are all very good positives, but there are some drawbacks to rounding in subacute care facilities.

  • The largest drawback is compensation.
    • A facility will almost never hand over a lot of patients to you on day one. You will most likely start from scratch and start off by building your census. Being on call 24/7 for a census of 5 people in these facilities for the first couple of months makes it a less attractive work environment for many doctors. There have been times where I drove an hour to a facility I was trying to build my census. There I would see my patients and bill a level 3 follow up on 3 patients (not everyone needs to be seen every week). When I subtracted money spent on gas, I made around 10 dollars an hour for some of the days when I was starting out.
  • Hours can be long and sometimes there are difficult family meetings.
    • Patients are older, chronically sick, and need a lot of time. To do a wonderful job, these types of meetings can not be rushed and can be lengthy.You most likely will have to travel to several facilities.
  • You most likely will have to travel to several facilities.
    • In order to build your census, you will find yourself rounding at multiple facilities. Driving from facility to facility takes time and you will not be getting reimbursed for your travel unless you write it off on your taxes.


What About Becoming A Medical Director

Most states have a law that post acute care facilities need to have a medical director. The medical director gets paid to help make policies, oversee the treatments of patients in the facility and conduct monthly meetings. The pay can range between $2,000 a month to $8,000 a month for most facilities.

Medical directorship makes rounding at skilled nursing facilities much more attractive to physicians. After building a census at the facility, you may be asked to be a medical director. This comes with extra financial gains but also increases your risk. You are responsible for everything you sign off on for the facility. There is no such thing as a free lunch.

An absent medical director is inviting legal problems and poor care for patients at the facility. Do not accept this position thinking you will be only collecting a paycheck monthly.


Competition Is Here

Large groups such as Team Health or Sound Physicians has been expanding into subacute care for years now. With the aging population and baby boomers on the rise, the need for skilled nursing services will keep growing. In 2017 alone, approximately 43% of all discharges from acute care were to a skilled nursing facility.

The large organizations have taken note and have started to employ physicians in this environment to broaden their reach. Almost every large city has at least 2 competing large groups that see the vast majority of patients in subacute care. Breaking into this market as a solo physician is becoming exceedingly difficult.


My Overall Experiences In Subacute Care

I enjoy my worn in subacute care. However, now that my business has taken off I have decided to step down from all my subacute care positions. The work was satisfying, and the money was okay. In the end, the traveling from facility to facility was too much for me to handle. Too many times I have been stuck in traffic only to get to the next facility over an hour later.

If you can find the right facility and potentially get an NP or PA to cover you in the facility, then subacute work can be a pretty nice benefit to any physician.







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