Many doctors emerge from their medical training with little knowledge of what and how they are paid. It seems counterintuitive that, after such extensive education, physicians still need to learn about something so fundamental that will affect the rest of their professional lives. In learning the business of medicine, physicians should start by gaining an understanding of their own compensation structure to avoid costly mistakes in their employment agreements.  

One of the most important standards against which a physician’s work is measured, and for which he or she is compensated, is the relative value unit (RVU). Understanding RVUs and their impact on earnings can go a long way toward helping physicians negotiate favorable employment agreements.

What Is an RVU?

Each procedure or service performed by a physician is assigned a CPT® code. “CPT” stands for  Current Procedural Terminology and is a registered trademark of the American Medical Association (AMA). 

Each CPT® code is, in turn, associated with a specific RVU value, used to measure the value of a service in order to determine reimbursement for that provider. RVUs are set somewhat arbitrarily by Medicare to account for the time, training, intensity, and skills needed to deliver such services. 

The RVU is then multiplied by a conversion factor, which is typically defined in an employment agreement. The number of RVUs generated by a physician is considered to be a measure of that physician's productivity for a given period; as such, a physician's RVUs will be tightly correlated to his or her compensation.

Easy Versus Hard RVUs

The concept of “easy” versus “hard” RVUs may not make immediate sense to a non-physician, but almost everyone understands the difference between high-return/high-value and low-return/low-value activities. For physicians, the idea of easy versus hard RVUs stems from the fact that certain procedures, office visits, and other tasks may be difficult and time-consuming, but generate fewer RVUs. Other activities, such as education and administration, produce no RVUs at all. Such activities are thus considered to represent hard RVUs. To maximize their compensation, physicians usually attempt to do the work that produces the most (or easiest) RVUs. 

That said, all work must be completed, no matter how many or how few RVUs are produced as a result. Conflict is the predictable result in an organization in which a few doctors are obtaining all the easy RVU work, while others are assigned mostly hard RVU tasks and procedures. 

When negotiating employment agreements, doctors must be aware of work distribution and RVUs tied to particular services, so that they are not doing most of the work for the least amount of RVUs. In cases where this disparity arises, doctors should negotiate a stipend or other compensation tied to particular activities, such as a directorship, that do not produce RVUs.

Initial Guaranty

Most physicians receive guaranteed compensation for the initial term of their employment. This initial term generally lasts from one to three years, but up to five years in certain cases. During this time, there is a compensation floor below which a doctor's compensation cannot go. 

Physicians must educate themselves on their RVUs during this initial period. Why? When the initial employment periods expire, their compensation guaranties cease as well. At that point, these doctors will most likely be subject to a general, RVU-based productivity and compensation formula that is also used for most other department physicians employed beyond their guaranty period. A physician’s knowledge of his or her RVU production — and the value of these RVUs — can help when negotiating a subsequent employment agreement.

Before employment begins, doctors should also try to obtain a bonus for excess RVU production during the initial guaranty period, in case the work assigned is more than a physician expects.

Target RVUs

Physicians also should ask potential employers about the typical RVUs generated and expected in their departments. In particular, ask for information about what other physicians, who have been practicing for a similar amount of time, are generating in terms of RVUs, and about the average RVUs per year in their department. 

Physicians also should ask at least quarterly for a report of their RVUs, so they are not surprised by a sudden decline in compensation. In some circumstances, physicians have owed the employer money after he or she generated insufficient RVUs in a particular period. It is also important to know whether RVU targets are realistic. Such information can also be helpful in negotiating attainable bonus formulas.

Audit Your Own RVUs

All physicians should get in the habit of auditing their own compensation. Doctors often find errors in their accounts, even when working for large employers such as hospitals, where one might assume that technology would reduce the likelihood of mistakes. 

Doctors must be aware of their typical RVU production. Should compensation during a given period decline suddenly, they will be better prepared to check their RVUs to make sure they were correctly recorded. Sometimes, doctors who spend entire days working in labs or clinics have had that time inadvertently omitted from their production reports. Had such discrepancies not been discovered, they would not have obtained credit for the RVUs they generated during those times.

Work Smarter!

Most physicians work very hard. They must also work smart. By understanding the basis of their compensation, doctors can ensure that they are fairly reimbursed for the work they do and that they achieve their financial goals. Doctors should educate themselves on their RVU production and have all employment agreements reviewed carefully to protect their financial futures.