> ## Content Index > Fetch the complete content index at: https://www.financialfellowship.com/llms.txt > Use this file to discover other available public pages before exploring further. # CRNA and CAA supervision ratios are in the contract. Deal breaker or daily irritation? - URL: https://www.financialfellowship.com/anesthesia-new-attending-supervision-ratios/ - Published: 2026-10-11T04:38:49.000Z - Updated: 2026-10-15T07:38:08.000Z - Author: Ryan Inman - Tags: #topic-anes-new **Medical direction allows up to 1 to 4**. Know **whether your group runs 1 to 2, 1 to 3, or 1 to 4**, and what happens when someone calls in sick. The ratio decides your day. The ratio is the job description. A 1 to 2 day and a 1 to 4 day are not the same profession. One is mostly hands on anesthesia with a colleague beside you. The other is constant prioritizing across four rooms with four inductions that never line up conveniently. The pay, the liability, and the exhaustion all follow the number. Ask for the number. ## What the ratios mean Under Medicare's medical direction rules, a physician can direct two, three, or four concurrent cases involving CRNAs, anesthesiologist assistants, residents, or a mix. To bill it as medical direction, the physician has to meet seven conditions: pre anesthetic evaluation, prescribing the plan, personal presence at the demanding parts like induction and emergence, making sure a qualified provider does the rest, monitoring at frequent intervals, being physically present for emergencies, and post anesthesia care. More than four concurrent cases is medical supervision, a different billing category. [42 CFR 415.110](https://www.law.cornell.edu/cfr/text/42/415.110?ref=financialfellowship.com) sets the medical direction conditions, and the [Medicare Claims Processing Manual chapter 12, section 50](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf?ref=financialfellowship.com) sets the billing framework. The AANA billing basics checklist lays out the seven requirements in plain language. Medical direction pays the physician 50 percent of the allowable for each case, with the directed provider billing separately. Personally performed anesthesia pays the full amount. That split is the engine behind every ratio conversation in the country. ## What each ratio feels like in practice 1 to 2 is close to doing your own cases with help. You are in the rooms most of the day, inductions rarely collide, and you know what is happening everywhere. The trade is throughput: fewer concurrent cases means less billed volume per physician. 1 to 3 is a common medical direction setup. One room is usually turning over while you are inducing in another. A decent team makes this a good day. A weak team, or a day with three complicated patients, makes it a sprint. Most groups that say "we run a good team model" are describing 1 to 3 with decent staffing. 1 to 4 is the most Medicare pays as medical direction. Above four, cases bill as medical supervision, which is legal at lower pay. Four inductions across four rooms with overlapping turnover is a management job that happens to require a medical license. The day is decided by the schedule, not by you: if three rooms need you at once, you prioritize, and prioritizing is the job. None of these is automatically the wrong answer. The wrong answer is signing up for one and working another. ## How the ratio changes your pay Illustrative math, not a quote. Take a commercial conversion factor of $60 per unit and a 10 unit case. Medicare's anesthesia conversion factor is about $20\. Personally performed, the case is worth about $600\. Medically directed at 1 to 4, your share of four such cases is about $300 each, or $1,200 across the four rooms. The higher ratio can generate more revenue per physician hour, which is why management companies love it and why some of that revenue should show up in your compensation. That is the question to ask: if the group runs 1 to 4 and bills accordingly, where does the spread go? Some groups pay a premium for high ratio direction. Some pocket the spread and pay the same rate they would for a 1 to 2 day. If your pay does not move with the ratio, the ratio is revenue for someone who is not you. ## How the ratio changes your liability You are responsible for the cases you direct. The seven conditions are not suggestions. When you are directing four rooms, you are asserting that you performed or oversaw each of those steps in each room. The liability scales with the concurrency whether or not the pay does. This is also where the sick day question matters. A group that runs 1 to 3 with full staffing becomes 1 to 4 with one callout, and it becomes an unstaffed room problem with two. Ask what happens on sick days before you need the answer. Good groups close rooms. Stretched groups stretch you. ## What happens when someone calls in sick This is the real ratio. Ask it directly: "Walk me through last Tuesday when two CRNAs called out. What did the anesthesiologists do?" If the answer is that rooms closed and cases were delayed, the group protects its ratios. If the answer is that everyone flexed to 1 to 4 or 1 to 5 for the day, the group just dropped into supervision billing. Also ask who decides. If the medical director can close a room, ratios are protected. If the surgery schedule decides and anesthesia adapts, the ratio is whatever the OR needs. ## Questions to ask before you sign - What is the usual direction ratio on a normal day, and what is the contractual maximum? - What happens to the ratio when someone calls in sick? Who has authority to close a room? - Does my pay change with the ratio? If I direct four rooms, do I earn more than directing two? - What is the team's experience level? A 1 to 4 day with four senior CRNAs is a different job than 1 to 4 with new graduates. ## Follow up questions Is 1 to 4 a deal breaker? It can be either. For some, 1 to 4 with strong colleagues and real pay for the volume is a great job. For others, it is a two year burnout with a clawback attached. The deal breaker is not the number. It is the number paired with weak teammates, flat pay, and no room closure policy. What is the difference between medical direction and medical supervision? Medical direction covers up to four concurrent cases when the physician meets the seven conditions, and Medicare pays the physician 50 percent per case. Medical supervision means more than four concurrent cases, with a different and less favorable payment structure. Does the ratio affect my noncompete or tail exposure? Not directly, but it affects your burnout risk, which affects your probability of leaving, which is when the noncompete and tail bite. A job you are likely to leave in 18 months makes every exit term more important. Price the exit stack against the real job, not the brochure. Can the ratio change after I sign? It can and it does, usually when staffing drops. That is why the contractual maximum and the sick day policy matter more than the day one ratio. Get the ceiling in writing, not the average. Who do I talk to for a picture of the ratio? Two anesthesiologists who left the group in the last two years, not the two the group introduces you to. Ask them what the ratio was on their worst week. The worst week is the number. ## Sources - [42 CFR 415.110, conditions for payment: medically directed anesthesia services (accessed October 10, 2026)](https://www.law.cornell.edu/cfr/text/42/415.110?ref=financialfellowship.com) - [CMS, Medicare Claims Processing Manual, chapter 12, section 50 (accessed October 10, 2026)](https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf?ref=financialfellowship.com) - [American Association of Nurse Anesthesiology, anesthesia billing basics](https://www.aana.com/wp-content/uploads/2023/01/anesthesia-billing-basics-considerations-checklist.pdf?ref=financialfellowship.com) (accessed October 10, 2026) - [American Society of Anesthesiologists, practice management resources](https://www.asahq.org/quality-and-practice-management?ref=financialfellowship.com) (accessed October 10, 2026)