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How to Negotiate Hospital Call Pay as a Private Practice Physician or Group

Aug 28
12 min read

Many private practice physicians in our online communities for doctors find themselves being asked to provide free (or poorly compensated) call coverage to the hospitals that they have privileges at. Depending on your specialty, what’s customary may be different, and there may be different advantages of taking call that have secondary benefits or provide significant compensation for work you do when you’re on call. However, for some private practice physicians, the compensation they receive may not be worth the opportunity costs of being available. Below, we’ll cover how to approach call negotiations with the hospital, with points for demonstrating your value, data from our communities and elsewhere, and what to keep in mind in deciding how hard to negotiate. 


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How to structure your hospital call pay proposal as a private practice physician


Do private practice physicians have to provide call coverage services to the hospital, and do hospitals have to pay for it?


The answer to this question - and likely the one that determines how much leverage that you have to negotiate call pay as a private practice physician or group - depends on:


  • What the hospital bylaws in terms of what services you need to provide if you have admitting or operating privileges at the hospital

  • How much they need you vs how much you need them

  • What your other options are at other hospitals or surgical centers

  • How much of your revenue comes from services delivered on call


The fact is that many physicians do have to provide call in some form, but the bigger question when figuring out the exact arrangement is who needs who more.



Start with figuring out your value to the hospital vs their value to you, and where the balance of power is


Call is a complicated discussion, because it varies so much from specialty to specialty. There are some specialties that absolutely need operating and/or admitting privileges at the hospital. For them, it’s a matter of figuring out which hospital they have access to that gives them what they need in terms of resources and the best terms associated with it (best block time, call requirements, compensation, etc).


Other specialties or private practice groups may not necessarily need everyone in their group to have hospital privileges, and it’s more of a sell that hospitals have to make to the physicians to participate in their call pool or bring their cases to their facilities.


Hospital bylaws will often have blanket statements to ensure the viability of the call services they need to provide to run their facilities, provide their patients with access to specialists, and/or have somebody on call in a particular specialty to fulfill trauma center designation requirements.


Similarly, some physicians may be able to walk away from the negotiating table, whereas others will have a harder time. If you rely on the patients coming in through the emergency room for you to get your interventional cardiology cases, for example, you’re likely going to have to take call, and probably can’t walk away entirely. This doesn’t mean you won’t have any leverage, but you may have less than the dermatologist that doesn’t need anything from the hospital to run a successful practice.



Before you negotiate, figure out what you’re actually negotiating 


Salary is only one piece of the call negotiations process, and separating out the pieces may make it easier for you to negotiate favorable terms or more compensation for particularly painful or valuable pieces of it. 



The pieces of a call services contract negotiation


Here are the various services you’re really negotiating when you’re negotiating call:


  • Availability: When you take call, you’re agreeing to be on standby for the hospital that entire time, regardless of whether you’re actually called in. The obligation you take on to be reachable during that time, and the windows you agree to respond within all have an opportunity cost that you should charge for.

  • Clinical work required by call: Understand exactly what you’re agreeing to. Are you just covering the ED and need to be available for consultations, or are you handling inpatient consults, admitting patients, doing emergent procedures, answering phone calls from inpatient teams or patients, etc?

  • What can be in person vs over the phone:  it’s important to know what you need to come in for and where you can just provide guidance. Also, if there’s a required response time by which you need to be on site to take call for a particular thing, factor that in to what you agree to.

  • Weekend and holiday responsibilities: Call during these times can generally command higher compensation

  • Underinsured or uninsured care: If part of the hospital’s argument is that you are getting paid by the billing you generate, you want to understand how many of the services you provide might not result in payments secondary to under- or un-insured patients. Understand the patient mix and case mix and if you’re likely to be doing work you won’t be compensated for by insurance or another payer, you may want to negotiate a separate arrangement or payment from the hospital for these cases

  • Associated administrative duties that may come with taking call: will you have to participate in meetings re: protocols, help create the call schedule, etc

  • Malpractice exposure: Do any of the responsibilities requested result in malpractice exposure you might not have otherwise that will affect your premiums or the coverage you need to secure?


The 7 parts of a call services and pay contract negotiation private practice physicians should be aware of

Refute arguments that other private practice physicians don’t get paid for call


We have lots of statistics about call pay here on our article on statistics on on call schedules and compensation for doctors, but we have physicians in every specialty who are in fact getting paid for call, and this number seems to be rising every year (and has likely risen since those statistics were published. 


Older data from a Becker's Hospital Review summary of hospital survey data published in 2010 reported that 82% of hospitals paid at least some independent physicians for on-call coverage. While these numbers have likely changed given how old the study is, there’s still some good information within it. 


Importantly, they reported determining call compensation primarily through negotiation with each physician or practice, so it’s important that you negotiate well on your behalf. The factors hospitals in that study said they considered included (from greatest to least) what local and national market rates were primarily, and then frequency of call and the likelihood of being called in, followed by acuity/intensity, payer mix, inpatient follow up required, and malpractice risk.



Determine your talking points for why you are valuable, why you need to be paid or paid more, and what the consequences would be if you didn’t provide call services


Ask what the hospital would do if you weren’t providing call services


This is the usually the most leverage private practice physicians and practices have when negotiating call with the hospital. It will force the hospital to think about how many more physicians they’d have to employ (with all of the associated costs, benefits, and need to recruit), what other practices may charge them, whether they’d have to hire locums, or bigger things like whether they’d need to reduce services, change their trauma center designation, transfer patients or shut down certain units, have to put the ER on diversion for certain services, or otherwise complicate operations.


Note, this shouldn’t be posed as a threat, but rather as a way to contextualize the value you provide.



Quantify the burden of call so they can see what the real opportunity cost of call is, and make a business case out of the historical data that you have


Instead of making a vague statement about how call is a lot of work, outline how many nights and weekends in a year you’re giving up, and show them historical data about how many times you have been called in, how many ED and inpatient consultations were performed, how many admissions were done, how many procedures were done, the number of patients that were under insured or uninsured that resulted in no payments to you, the number of transfers having you around precluded, etc. If possible, go into more depth about how much revenue was generated for the hospital by these actions.



Outline what having your services allows the hospital to do


Statements about the value you provide that are backed up by data can be very powerful. Some examples:


  • “Our physicians provide specialty coverage, including x, y, and z, that the hospital or hospital employed physicians can not otherwise reliably provide.” 

  • “Because our group takes call, patients can be admitted and treated here rather than transferred. Over the past year, we handled X cases that otherwise might have required transfer.”

  • “Our availability allows the ED to provide timely specialty consultation, which facilitates quicker disposition and better turnaround times and throughput through the emergency room, which raises patient satisfaction scores and frees up beds.” 

  • “Our services allow you to provide x, y, z procedures 24/7 that you would not otherwise be able to do afterhours, which would disrupt your working day schedule in x way and prevent patient discharges, increasing length of stay.”

  • “Our afterhours coverage is an operational requirement of maintaining the ability to offer service X based on CMS’ EMTALA or Level X Trauma center delegation.”



Determine your talking points for why you can’t take call for free or at low rates


  • Outline opportunity costs of taking call, including patients you might not be able to see at your private practice or hours that you couldn’t offer afterhours or weekend services at your practice

  • Point out that regardless of how much you’re getting called in, there is a cost to having you on standby - “If I can’t go out of town or have a drink at dinner or commit to coaching my kids’ team, there is a price for that.”



If you’re asking for a raise in your call rates, have data to back it up the request for increased compensation


Don’t ask for raises - ask for market resets to reflect the current market rate or opportunity costs. Nobody will give you money just because you want more money - you’ll have to show why you need to make more to keep doing it.


Good data to pull in includes a request for more call days, less physicians sharing call, increased call responsibilities, increased volume, increasing complexity or acuity of case mixes, imposition of different response time requirements or other requirements, more asks for holiday or weekend coverage, changes in payer mixes resulting in less compensation from the clinical work, an increase in the number of procedures being requested, increased malpractice costs associated with the work you’re doing, the inability to moonlight or do other side gigs when you’re on call, etc. 



Ask them for data directly about what others in private practice get in terms of call pay


One negotiation tactic may be to ask them to pull data themselves so they can justify what they’re paying you. Ask them for trends, for what they’re paying other physicians in the call pool, etc. If they refuse to give you information, ask for if the hospital has an FMV opinion or valuation report for physician call coverage, and whether your rates fall into that (ask to see the data as a measure of good faith in negotiations). This will make it harder for them to continue to negotiate in good faith without giving you some information you can use to make your case.



How to negotiate the hospital medical bylaws issue if it’s being used against you


Some hospitals will tell physicians that the bylaws require them taking call, and that they don’t have a choice because federal law requires every physician with privileges at the hospital to take call. 


This isn’t true - CMS has specifically put out a statement saying that there is no EMTALA or Medicare provider-agreement requirement that every physician with hospital privileges must take call, and that hospitals can have policies providing exemptions.


Therefore it’s important to  clarify the statement and see what the hospital bylaws actually do require. Many hospital's medical staff bylaws actually do condition your category of privileges/membership based on call participation, and this is where it gets tricky. The exact wording of the bylaws measures a lot. 



Gather the documents and do your due diligence on what is actually required


Obtain the actual documents for medical staff bylaws, hospital rules and regulations, the credentials/privileges policies, the call policy, medical staff categories, any call exemption or community call policy documents, etc. 


See if there are any exceptions that apply that can help you negotiate.



What to do if call is mandatory


Mandatory doesn’t automatically mean unpaid. Additionally you could negotiate an amendment to the bylaws for yourself or your practice. Using the points above as leverage and threatening to walk away (assuming you can) will likely prompt deeper conversations than the automatic ‘no.’


You may want to involve a lawyer in this process, because you need to make sure that you aren’t running afoul of any Stark, FMV, or other statutes in regards to the compensation that you negotiate. For example, you should not ask to tie your proposed call compensation to the number or value of patients you refer to the hospital, but you can totally ask for a commercially reasonable, FMV-supported payment for call coverage.


Related PSG resources:



Structure for your final proposal


Once you’ve navigated all of the things above, you’ll want to come to a final proposal. Part of this will depend on how complicated you want to make it, but instead of just saying, “I want $1000 per night I’m on call,” consider if you would come out ahead with a more complicated structure such as: 


  • Availability stipend that just covers you being available

  • Payment for work that is done (this may be the insurance payments you collect, if applicable, but if not, any other way to get compensated for services provided)

  • Separate delineated premiums for nights, weekends, holidays, in house call, specifically high volume periods, or particularly burdensome call shifts


Remember, you are not a hospital employed physician, so standard arguments about what is included in call or it being included in your salary or outlined contractual responsibilities don’t hold up in these negotiations. What they do with their employed physicians is not your concern. 


Never start a negotiation by offering the lowest you’d do it for. It’s important to set goals for rates. If you need help knowing what’s reasonable for rates, look at apples to apples comparisons on our full call compensation database (accessible to members of our physician communities only). Some aggregate data can be found in this article on call compensation by specialty. 





What to do if you can’t come to terms for call compensation (and how to determine your BATNA in the negotiations)


As we alluded to earlier, and in general in every negotiation you do in your life, it’s important to know when and how you would walk away. 


Know your alternatives that would allow you to threaten to walk (not because you want to set up a contentious agreement, but the hospital you’re negotiating with should understand that you have options, some of which might not be what they want. This includes getting privileges at another hospital that doesn’t have the same call and compensation issues, providing services for a competing hospital which would allow that hospital to offer services this one couldn’t, and applying for modified privileges that don’t require call instead such as non-admitting privileges or outpatient only privileges.


All of these things will force them to consider the costs of not having you in the call pool and will increase your leverage when asking for appropriate compensation.



Conclusion


Ultimately, when negotiating call compensation, you’re going to want to remind the hospital that you or your private practice group is providing the hospital a service that requires you to reserve physician capacity, remain available on standby to respond to emergencies, assume professional and malpractice risk, and limit your ability to practice elsewhere during call. You’ll want to lay out that argument with facts and data, as well as show them what would happen if you weren’t providing coverage, to support your goal of getting adequately compensated for the valuable service that you provide! 



Related negotiation resources for physicians 


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