Hospital and ASC (ambulatory surgery center) privileges for the solo doctor

Originally published by Ho Sun on December 12, 2010: Once I secured my office address, I also applied for hospital privileges.  Unlike Medicare, private insurance carriers require providers to have admitting privileges at a hospital in order to be credentialed (note: see addendum below).  Some insurance panels claim that this requirement can be waived for outpatient specialties like ophthalmology.  However, I doubted that credentialing departments would put in that extra work to do so.  I thought that my application would just be placed on hold if I applied without hospital privileges.  Hence, I chose to delay my private insurance credentialing until I was granted hospital privileges (again, see below).  Obviously, I was motivated to submit my hospital privileges application promptly.

I only applied to one hospital: O’Connor Hospital, which is 1 mile away from my office.  Back in July, when I visited the Bay Area for 2 weeks, I met with the physician relations correspondent at O’Connor.  He gave me a tour of the hospital, and also introduced me to the medical staffing department, who gave me an application packet.

The application requirements were similar to Medicare.  Along with the application, I had to submit copies of my California medical license, residency and internship diploma, medical school diploma,  DEA certificate, malpractice insurance, and CV.  I also provided 3 professional references and my intentions for board certification.  The application fee was $300.

I also had to find an ophthalmologist to provide alternate ER coverage for me.  Obviously, for people who are completely new to the area, with no connections, this part of the application can present a significant hurdle.  Thankfully, one of my attendings from residency had introduced me  to one of his former fellows a few months back, who was coincidentally affiliated with O’Connor Hospital.  I’ve met with him previously, and he was kind enough to sign the alternate coverage agreement.  I offered to do the same for him.  Just out of curiosity, I still asked the medical staff office how I would go about finding alternate coverage if I had no existing relationship with any staff ophthalmologist.  The office person told me that I would just have had to just go down the staff directory, and to randomly solicit people.

In terms of the type of privileges, I applied for everything, including admitting, consulting, and ER privileges.

6 weeks after I submitted my application, I was invited to interview with the department of surgery at their monthly meeting.  This interview was purely a formality.  The whole thing lasted 5 minutes, and “hello” and “goodbye” were pretty much the only words that came out of my mouth.  The department chair just went over a few housekeeping rules.

4 days later, the credentialing committee reviewed my application.  Since I had a clean application, with no prior disciplinary action, lawsuits, or denial of my credentials, the committee granted me temporary privileges immediately after their meeting.  At this point, I submitted my private insurance applications.

The board of directors will meet next week, which is 3 weeks after my interview, and I should be granted full, unrestricted, provisional staff privileges that day.  After 1 year, I should be eligible to obtain active staff status.  It seems like most hospitals only grant provisional privileges to newly credentialed physicians.

As a provisional member, my first 3 cases will be proctored by an active staff member. I’m fine with that.

Howie’s addendum: in most areas you need to have active malpractice insurance before your hospital privileges can be active. If you are covered by another insurance in your previous job or aren’t practicing between jobs and need to get OMIC they will let you fill out the application but all you to conserve cash paid for premiums by not activating it (start paying for coverage) for 90 days if you need time for your real estate search.

In my experience you do NOT need active hospital privileges for credentialing for most private insurances. When I started my HMO job I was in the process of applying for hospital privileges yet I got onto most insurances. They were so slow it took them an entire year after I started employment to get me on staff! (Fortunately, this also meant that I didn’t have to take hospital call the first year I worked there😀)

Most hospital medical staff applications can be found online, on the hospital’s website but I agree that it’s nice to go in the medical staff office and personally introduce yourself, some of them are actually now my patients and have referred hospital employees and patients to me.

In terms of finding call coverage, you can get a list of other docs in your field on staff and phone them to see if they will help. It isn’t really a big deal for ophthalmology because we rarely have inpatients to cover.

Before you apply for hospital privileges be sure to find out if the hospital requires call and how much they compensate for it. Make sure you’re being treated fairly.

One thing I wish I did differently when I opened was to apply for more hospital privileges. I am on staff with each of the three major hospital systems in town. This allows me to join their ACOs (accountable care organizations) which gives me access to patients in narrow network or Medicare advantage plans affiliated with the ACOs. You are not obligated to join every plan that they are affiliated with, so you are free to negotiate or opt out if the reimbursements are too low. None of these hospitals make me take call.

Finally, at the same time you look at hospitals, you should also be looking at ASCs (ambulatory surgery centers). If you are employed, your employer will often dictate which ASC you operate at. If you go solo, definitely go on a tour of the ASCs in your area. Just like with hospitals, it is a good idea to get credentialed at multiple ASCs. Some of them might be in network for some insurance plans but not others, and you can take patients to certain centers based on the plan, or geography if you have a satellite office. Most ophthalmologists operate at ASCs rather than a hospital, with the exception of possibly oculoplastics. Sometimes the ASC is next door to the hospital and partially owned by the hospital system. You still need to credential separately with the ASC. I found the credentialing to be much quicker and faster for ASCs than for hospitals.

Ask if you will be given block time (a fixed time to operate, rather than filling in empty slots which can wreck havoc on your clinic schedule), and when that block time will be (Thursday PM is a common time to put in the “new guy”). See what the equipment is like, and if they will need to purchase a lot of new equipment to accommodate you Sometimes you have to buy such equipment or bring it yourself, be sure to ask. Find out how long or short the room turnover is, and if you are there other cataract surgeons there, if you can be given two rooms. I’ve heard the break even point for two rooms is about 10-12 cases, but if you are in the afternoon following a busy surgeon in the AM they may still keep the staff there and give you two rooms.

Make sure the scrub techs are experienced in your field. This is particularly true if you are retina or plastics, even if you join a group. It’s no fun when the staff don’t know what to expect and are not on the same page as you. Bring copies of your instrument preference cards (which often indicate the ways you do surgery and when the instruments should be handed to you) from residency, fellowship or your previous center and go over everything and make sure the instruments are there and the phaco machine is properly programmed BEFORE your first day at the surgery center! One surgery center I went to, I actually paid my scrub tech (out of my own pocket) from another center to come do my cases with me because I didn’t trust the staff there!

Find out who owns the surgery center (solely hospital system, solely surgeons, or 50/50) and if you will eventually be allowed to buy in and become a partner.

If you go solo and get really busy or hire employees, you might want to eventually consider building your own ASC. In some states this is difficult to do as you must obtain a certificate of need. The rules and regulations are much stricter compared to running your own medical practice and office, and I don’t claim to completely understand these rules nor the financial aspects. If you are joining a group, be sure to follow the advice above, and when you are offered buy in to the group, you should be allowed to also purchase ownership in the surgery center.

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