Post Turkey Post

Let’s talk cold turkey.  Who is ready to do locums? What things do you have to consider?   

Insurance

this is a big one and i hate paying people in the off chance i need insurance.  I would rather put my money to work for me so that it can pay for what i need in the future.  Alas, i still pay for the family insurance for health, vision, dental and then have a malpractice policy.  I put up that we have liberty healthshare, some form of VA, and Cigna PPO.  Vision is VSP pro and dental is Delta Dental if i recall.  Malpractice insurance is through the AANA.  Are these perfect? Nope, and they don’t cover everything.  I’m on my way for a sleeve gastrectomy in Mexico.  I have tried every weight loss plan known to man and am doing this not because insurance thinks it’s a good idea... in fact they do not cover weight loss surgery even in morbid obesity.  It’s a $9,000 surgery and not covered.  I’ll see if they will cover any portion but my guess is no.  

Time off

I absolutely love and hate time off.  I love it because i work hard and want to truly enjoy life.  I hate it because i am losing income and spending $$.  I do everything i can not to miss paychecks in the year!  Being a locum does allow me to take months off per year if i need it though.  My daughter was born in January and I didn’t go back to work until March.  I contracted for the 2.5 weeks over thanksgiving to be off for surgery and vacation.  I’ll also be off all of January this coming 2018.   

I’ll also be speaking in Costa Rica for an hour in January!  sooooo, you can see time off can be had and when it’s important.  That doesn’t however mean that i tell facilities i can work only special hours or days.  I tell them I’m here to work.  Work extra??? Most times that is a hell yes! 

What else? 

there is plenty to talk about!  Let me know what you think.  Locumcrnas@gmail.com

Hello Hawaii

Here i am in Hawaii and I’m working on credentialing paperwork for the hospital and home loan paperwork for the mortgage.  It always seems i have to do some work on vacation.  I guess that’s part of being an adult these days.  

I try to be complete in getting things returned very quickly.  I told everyone that they should have paperwork done as I would be on vacation.  I figured I’d get some mortgage stuff as my brother is my broker and he is here... but credentialing for the hospital.  Canitant that I’ve done the agency/group/ and now hospital credential paperwork?  I know some hospitals third party credential... but why is it we can’t be centrally credentialed?   

I guess i can see how it would be negative because if you had any speed bump that would keep that group from credentialling and you’d be out of a job anywhere.  I just don’t see how we can get so many background checks?  Mine has been checked about every 6 months since i was 18. 

i hope i get in on that central credentialing agency! :). Granted it would likely be run by the nbcrna, aana, or nursys :) 

Lessons Learned

As a locum, one must remember the business is part of the game.  Speaking with groups, recruiters, doctors, & CRNAs is part of that.  I’m still learning but here’s what I know so far. 

Keeping doors open can be your best opportunity.   — don’t burn the bridges you traverse frequently.

Understanding the market in the areas your discussing can help you but you may not want to tell everyone that you know the market rates.

Until you have a signed contract you have nothing.  If you sign a contract ... honor it.

Be able to state things clearly but be flexible.

Knowing your abilities and being able to spin them in a good light will help you.

Negotiations for a long contract are possible but the company or group may want an interview just like being full time permanent staff.  

Never stop learning and keep your skillsets.  The skills that you have need to be tended and nurtured so as you continue your career keep your skills up.  If one place has a lot of one but none of the other... the next place should have what you are missing.  

Speaking of skills and education.  Review the CEU tab, State Meetings tab, and if you like us visit the Store for some small items we receive a small royalty on.

 

Liberty as an insurance provider? Is it for me?

People ask me quite often what I think of Liberty HealthShare. Most days I’m happy with them.  I have had great experiences and less than amazing experiences.  I am not a skinny person … I am about to go for a sleeve gastrectomy which is expressly not covered by Liberty.  Page one states they do not cover weight loss surgery.  I pay an additional premium and have conversations with a health coach showing that I am trying on my weight-loss and I have a plan and goal.  This is a requirement.  This would also be the same for a smoker and the plan to cease smoking along with a health coach.  Some hypertensive medications require the same. 

 

I started Liberty approximately last December.  My husband was not able to be insured by them as we stated his positive TB skin test revealed calcified lesions on the lung which mean he has had exposure.  This is not Medically treatable but the primary care physician was either not educated or not aware of the medical treatment and stages ofl TB classification and treatment.  They would not write in the record that TB treatment was not indicated nor needed.  Francisco uses US Health Group for his insurance.  Just one month later my biological daughter was born via Surrogacy in Mexico.  She was hospitalized from birth requiring additional medical test & procedures.  She was in the hospital for 12 days and the costs were over $1000 US per day.  It was my anticipation that no insurance would cover me.  Traditional insurance said that after 30 days they would cover my child.  I called Liberty and asked if I could add her from her date of birth.  They said yes and added her for $50.  I asked if they would cover any part of her medical bills in Mexico.  I was told that they would if they had the bill in English and in US Currency.  I couldn’t deal with this until I was at home over 2 months later after being very stuck in Mexico. 

I had the bills translated at a cost of about $150 US and sent everything certified and called them several times to explain.  The hardest part is the system for uploading bills is only set for one bill at a time.  I sent all to them and explained that it was a lot of money out of pocket up front.  They seemed to put a rush on it and with-in 2 months I had been fully reimbursed for the medical care of Elizabeth in Mexico.  She and I have since had all of our doctor’s visits this year.  We have paid our premiums and otherwise been reimbursed for countless exams and rule-out tests.  She had to be ruled out for cystic fibrosis both in Mexico and in the US.  I have had 1-2 urgent care visits for a cold. 

What’s the negative?  I have found no provider that will take Liberty as insurance and bill directly.  All have made me cash pay and be reimbursed.  This works while we are healthy or bills aren’t super high.  However, I worry about ER visits or possible surgery or Emergency that lands me in the hospital.  I know I don’t have 100K to pay a hospital bill… Thankfully, I have the insurance card and my assumption is that a hospital bill would come to me and I could send it directly to them or have them call the hospital billing directly if needed.  In the US they will let you out of the hospital with an unpaid bill.  In Mexico they would not let Elizabeth out of the hospital with an unpaid bill. 

Every appointment since has had about a 90 day delay in reimbursement.  It’s something I have come to expect.  Most providers give a significant cash pay discount and so the amounts for doctor’s appointments have ranged from $90-$1400. 

I will continue to use them as I know how they work and I believe the coverage is sufficient for now. 

This has been our experience so far.  Hope this helps.  To see a comparison of health sharing organizations...  The insurance page of the site and scroll down to health insurance

1099, 1099, 1099 And w2 just not the same

Here we have the classic problem of people stating that they are locum and they are not.  Wait, what do you mean I’m not locum?  Let’s look at some examples and define locum.  

Broadly defined a Locum CRNA is on that is in place of another CRNA.  This means that the individual is covering for a CRNA on vacation, sick leave, maternity leave, or the full time FTE has quit and they have not hired for that position.   This means we are covering for an exact and defined position.   

I’m 1099 and take a full time salary in one place with a contract for 42 weeks a year at one facility with the expectation that this contract is indefinite for years.  This is a 1099 provider that has a job.  Generally, speaking the IRS would frown on this and state that 1099 is not necessarily the best way to report your income and the employer could receive fines stating that you should be w2.  Under the definitions of 1099 the independent contractor chooses when he or she works, where, & determines the best way in which the job is to be performed.  This is technically true but if you look at past precedent you would also find that the IRS has asked for other 1099 to prove that the contractor is choosing contracts at more than one place and is not based in one long term should be w-2 job. 

im 1099 and I go to 4 hospitals in my area.  They pay me a different rate based on what they pay a daily worker and it’s higher than the w-2 rate.  I must be a locum right? Not exactly,  if you are staying in one area and u are filling in days you are very likely Per Diem.  Per Diem is Latin for daily. A per Diem individual can be used because the hospital or group doesn’t need a full time or specifically a part time person but a gap exist so a per Diem individual can come in a full the day.  This person typically has a w-2 job but wants to pick up a Day here or there.  Since they have a job they don’t need “benefits”. Thus they receive 1099 pay.  The problem is here that the individual has healthcare, PTO, disability, malpractice and retirement etc so doesn’t calculate or pay those out of 1099 pay.  The group may pay w-2 at 85$/hour and offer a 1099 person per Diem 105-110/hr.  Sounds awesome because we know every 5$ on a full time basis is $10,000 annually.  The problem is you didn’t calculate based on a locum calculation and you have undercut even your w-2 counterparts pay and become cheaper labor than even the regular full time folks.

I am a full-time 1099 traveling locum CRNA.  I have gone to long term hospitals and short term.  I filled in for the group that had a changeover of management. Then I filled in for a girl on maternity leave, and then I did vacation relief for a group over the summer.  This person only has 1099 income, goes to more than one location and may plan a couple months at a time or fills urgent short term needs in critical access facilities.  This person travels to wherever the need is.  We pick-up life wherever that need is for the duration of the need from 7 days to a month at a time.  This is rarely if ever shorter than a week.  We calculate our 1099 pay based on the necessity, cost of housing, food, gas, regional entertainment or lack there off, health disability and life insurance, time off needed in the year, and travel to and from assignments.  We factor in time away from family or if a spouse can’t work because we travel. Our rates should never undrcut a w-2 worker even the rate we work for from an agency.   Our rates shouldn’t be below $140 all inclusive per hour and should in areas of the country be as high as 180-200$/hR.  We have to be business astute and undestand taxes, business, retirement and finance.   

The W2 worker has a job that is not expected to leave.  They receive benefits and stability.  They accept a pay rate lower than all the 1099 positions as they don’t need to worry on taxes, retirement benefits, and vacation.  Most places cover malpractice and even disability insurance.  Because the group provides all this the pay is typically matched to the area and to the lowest denominator that will keep and retain a percentage of staff at the hospital and is generally calculable.   

These are literally just my thoughts and opinions on the description of each and are not intended to be all inclusive of every situation. 

If you are loving the site.... make sure you check all of it out.  If you want to support the cause there is a Support tab that has a sample contract and some things from Zazzle for sale that are CRNA specific :)

 

Accountant

I was told this week by a 1099 person that for years his accountant only allowed him to write off his cell phone.  I'm not sure what everyone does for their accountant.  Here is what I do: 

Quarterly, I send statements.  Bank statements, car insurance, phone bills, house payments, insurance, utilities, anything and everything!  I highlight any meals for work, meals out, any CEU or training, job hunting, computers, tablets, phones or anything remotely for work purposes. This includes printer ink, office supplies, shoes or clothes, my new stethoscope as my other was just getting old, my work bag, and car tolls.   

These are just a few things that can be on the write off side.   

Talk to your accountant.  Ask if they'll review EVERYTHING?  If not go to www.locumCRNA.com and find an accountant that will work for you.  They are listed in the financial section of the website.   

5 hours could bring you tens of thousands of dollars.   

1099 house

I'm a sole earner 1099 locum CRNA.  I have an accountant that does an excellent job.  Due to my propensity to do what I want at the time I want to do it, I am trying to buy a house. I have decided to buy a (for me) expensive home.  Expensive is anything I have to get a loan for.  So, there is this 360k house we have found that could be good for us for at least a few years.  

Paperwork on a normal w-2 loan process can be easier but generally it's been the same for me.   

Except, I have rental properties that are claimed as losses on my taxes.  I have my income written down significantly based on may exemptions, deductions and whatever magic accountants do.  My net income is 160k which is respectable.  However, if you recall rental homes, surrogacy and life are all expensive experiences.  Therefore, cars, loans, & credit are all taken into account.  

So,  although my income is significantly higher than appears and I save on taxes.  Now I need to be concerned for qualifying for a moderate home in an average city.  often times I hear that people need to claim a higher income and pay more taxes to buy more house.  I think that if I had less debt based on my income I could have pushed my loan amount to 600k on 160k of earnings which is just shocking to me as the payment would be pretty high for a supposed income level of 160k.  

The good news is that I am not looking for an amazing, blow it out of the water home. I'm looking for reasonable, decent re-sale, good schools, and place to let the dogs outside.  

I'm taking into account sale and realtor fees.  However, houses have been sitting on the market for a while at the current rates.  I'm moderately concerned that we could be at the top of the market.   

If that is the case we will need to watch for not over upgrading a house.  We'll need to recall that kitchen and bath are selling points.  Going too small with a high price or too large can mean that the home will be more challenging to sell. 

Buying a home makes it more challenging as a locum as well.  If looking to only do locums in one area it can be rough.  The hospitals will try to do per diem vs locum.  The housing amount provided going toward paying off a mortgage is highly important in keeping my plan alive for 5 years from now.

We will be looking at 2-3 houses today and if not impressed we have our home picked out.   

Will keep you updated as we go through this process.   

What is happening

I hate the idea of a W-2 or 1099 job... or is it just a job?  You know what that stands for right.... Just Over Broke.  Here is what I'm thinking?

Many CRNAs in this area have been here a long time and many are ex-military which is awesome.  Highly trained and reliable workers utilized to care for the region.  This is perfect except for the problem.  They don't need benefits and they don't always know their value.  So, many are 1099 ... can you believe I've heard one place pays 1099 90$/hr.  This is $50 an hour lower than most all-inclusive locum contracts and $85/hour lower than an AZ or NM contract I reviewed in the past couple months.  I want to plead with 1099 providers to know your worth and actually approach it with your expectation of pay!

I am a locum guy.  You know that.  Here is my concern and correct me if I'm wrong.  I'm looking for something in the Hampton Roads area for a year or so... could be 2 years could be 6 months.  Why?  We are working on a second child and we are in talks with a clinic in that area.  If all works out we would need to be in the area.  

So what?  I'm a planner and don't want to get to March and have to be there with no plan.  

There are jobs there... why not just take one?  --- I've been a locum for a while and take two jobs in 7 years.  Each one had flaws with my thinking in why I was there.  That said... I have a solid why for being in the area.  I look at these jobs and they pay less than I live on now.  Which either means taking two jobs or revamping life a little bit.  I had a plan to pay things off and get to my goal in rental houses by the time Elizabeth was 5.  I'm not certain that is possible in going to the area and doing surrogacy.  

The other thought is taking a full time yet not full time job and then supplementing as needed as a 1099 per diem.  The per diem is lower than I accept as a locum and causes the difficulty of having to work harder for the same pay :(.  

The other thought is to do locums in anther part of the state and drive 2-6 hours every time there is a medical appointment.  even the options for locums i am presented with would drop my pay by 10-20$/hour.  

 

A New Kid on the Bloc

A new kind of agency is emerging out of the cries for transparency and concern that CRNAs are working for the same pay as ten years ago.  Yes, we have seen some recent movement in the pay of CRNA locum providers in the past year. However, it still seems our pay is sometimes below or at that of w-2 providers with benefits factored in.   Part of this slight increase could be attributed to the education of providers and the demand for CRNAs to fill gaps as anesthesia management groups grow. 

BlocHealth is trying to prove a transparent model of bringing together platforms of providers searching for competitive but higher rates and groups/hospitals looking to decrease agency fees and overall hourly fees for the temporary workers. Win for both the client hospital or group and the contractor/provider.  This matching process is still a growth project where they are actively searching for exactly what our providers are looking for in the areas they are looking.  This could branch out into a system whereby “Employers” are independently contracting “Providers” through a web-based matching system and negotiating a contract more completely on-line.  Part of this may include a more automated credentialing platform where provider data is streamlined to the requesting hospital expeditiously.  Although there is no completely automated system, at this time, for the job-seeker and employer.  However, BlocHealth is an agency right?  Sure enough, they are an agency and their fees are still in place.  However, using an automated process and setting in motion an atmosphere of a less hands-on approach will allow for lower overhead and expense ratios.  What’s that boil down to?  Sometimes this is less than 1/3 the fees of a standard agency. 

I believe that this will put some of the credentialing process on the provider as there will initially be less funneling of paperwork to the hospital as a larger agency might initially do. This means credentialing would be of some effort on the part of the client.  We’ve all done this paperwork 100 times and have given the same information to either hospitals or agencies before.  This time it’s to get the rate you want and possibly the area you want to work in.   I believe that as the process grows this automation will decrease the paperwork burden. 

They are also up front in saying that at this point they want providers to state realistic rates, time-frames, skill–sets and areas of desired work.  Then BlocHealth is looking for positions that will fit the provider and group.  Where-as most agencies advertise positions open in hopes of getting a CRNA to fill them.  This may be known places that need help or calling in the region to see if groups are in need or struggling. 

Overall, I see intriguing changes for the future that could grow into a good niche with-in the locum world. 

Why do I say all this?  I called and talked to them.  I tried to understand the company dynamic and what it could be.  I put them up on the site and have a referral contract with them and want to know that they are trying to be clear and work for the follow through.  I even filled out my information on their site and found the process to be just about as easy as any other. 

I almost able to do all the paperwork on my phone.  Recently, I was told BlocHealth now has a convenient and easy way of accessing a personal folder on the cloud that contains all provider information in one place. 

I may just work with them in finding contracts for other CRNAs in the future. 

Students

SRNAs:  Because this comes up several times per month and I had an experienced CRNA ask me my thoughts.  Some will say they are appalled I would state this and some would back it 110%.  I'm going to explain the perceptions and then the exceptions and leave it out there.  

Seasoned CRNA: 

I didn't think most agencies would hire new grads.

Me:

No they typically won't. A few reasons and I don't say it to be mean. 1) most are wanting to credential before passing boards. They can't do that because a provider must be qualified to practice in order to be credentialed.  A facility hiring a new grad may go through all the steps of credentialing pending boards and licensure but both boards and licensure take time post graduation. Then the credentialing office verifies those two things and your off to the races.  Unfortunately, locums the facility can't guarantee you will pass boards and be licensed and therefor the same dilemma of time between graduation and taking a first job exists.  2) The SRNA pending CRNA isn't proven safe in an established practice for a period of time. If they have been in practice less than 3-6 months were they let go from a facility for cause either interpersonal dynamics or poor practice?? 3) Locums are used because a facility or practice is short of help and needs someone that has developed their practice and can jump in and provide skilled care in less than optimal conditions. 4). It can be hard to go from student mode to alone especially if most or all your education and training was 1-1 with someone always there.  This transition is helped by going to a practice that has people that can facilitate the growth from student role to provider role.  I believe this can be established in any role but some are definitely more challenging than others.  

For example some ACT keep CRNAs in a very restricted environment that can be more of a hindrance so the CRNA fully develops all of their skills.  Other ACT environments use CRNAs to their capacity but have the Medical Direction model and each does their part in a collegial practice.  Some CRNA only or private groups where both MDAs and CRNAs work on independent cases will say that you are a CRNA and should do only what you know.  Others will teach and build you up to the full capacity of that practice.  Still some only do a certain type of practice, which they are excellent at. However, they lose other skills and if branching out find a difficulty in full scope of practice. Solo practice... Most say a highly skilled CRNA of at least 5 years practice should go to these places.  This depends on training and the experience they had in 5 years.  If they have been doing blocks, spinals, epidurals, lines, kids, adults, critical to fast paced out patient for 5 strong years. That's what the solo practice is looking for along with someone that wants to learn and grow as a provider.  Really, this is what a locum agency and average short-handed facility would like too.

Am I saying that new grads have not gone directly into locums or solo practice?  Nope.  Am I saying they are poor providers? No.  I'm saying that it's not recommended and many agencies will discourage the practice of locums for new graduates.  Most request 1-2 years of practice to be comfortable in your role and discussing with medical staff regarding patient care.  

If you feel I've missed something please e-mail me and I am happy to edit this.  LocumCRNAs@gmail.com