My experience buying out a retiring podiatrist straight out of residency

[GreenGreen]

I finished residency this year. I started working at my practice mid July (bought from a retiring POD). Single practitioner.

I'm going to gross around 20k this month... and this is seeing around 10 to 15 pts a day with a mix of routine, sx candidates, wounds, bread and butter etc. Plus not seeing reimbursements for the 1st week of Aug. I have about 20 surgical patients lined up. Can't do elective sx due to covid surge in Texas.

It's amazing. I love working for myself. First week I worked about 12 to 16 hr days learning EMR, accounting, coding, etc. After a month I'm only working 8-12 hr days and still crazy busy with administration... but its starting to come together. I have only lost ~25% of the patient load previous Dr. Had.

Do yourself a favor and work for yourself.

If I have a consistant 30 pts a day x 4 days a week, averaging my $100-125 per pt (good coding, procedures, dispensing, etc). That's 600k+ easy. My overhead looking around 250k annual. 350k gross salary.

Don't listen to the toxic negativity within and without the podiatry community.

I just wanted to share my experience sand encourage others.

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[HardRoadPaved]

I finished residency this year. I started working at my practice mid July (bought from a retiring POD). Single practitioner.

I'm going to gross around 20k this month... and this is seeing around 10 to 15 pts a day with a mix of routine, sx candidates, wounds, bread and butter etc. Plus not seeing reimbursements for the 1st week of Aug. I have about 20 surgical patients lined up. Can't do elective sx due to covid surge in Texas.

It's amazing. I love working for myself. First week I worked about 12 to 16 hr days learning EMR, accounting, coding, etc. After a month I'm only working 8-12 hr days and still crazy busy with administration... but its starting to come together. I have only lost ~25% of the patient load previous Dr. Had.

Do yourself a favor and work for yourself.

If I have a consistant 30 pts a day x 4 days a week, averaging my $100-125 per pt (good coding, procedures, dispensing, etc). That's 600k+ easy. My overhead looking around 250k annual. 350k gross salary.

Don't listen to the toxic negativity within and without the podiatry community.

I just wanted to share my experience sand encourage others.

Congrats! There is something definitely nice about getting the reigns of a practice if the original owner had a similar mindset and remaining staff is ready to work for you. 15 patients per day x 5 days x 4 weeks = 300 visits. 20k/300 = $66/ visit.... keep aiming higher!

Do you mind sharing your general buy out terms?

 

[dtrack22]

I'm going to gross around 20k this month... and this is seeing around 10 to 15 pts a day with a mix of routine, sx candidates, wounds, bread and butter etc.

So you aren’t covering your overhead yet?

If I have a consistant 30 pts a day x 4 days a week, averaging my $100-125 per pt (good coding, procedures, dispensing, etc). That's 600k+ easy. My overhead looking around 250k annual. 350k gross salary.

If you are at ~13 patients per day, and that’s only a 25% decrease from the previous owner, then you’ll need to grow by over 100% to get to the above figures. The previous owner wasn’t even doing that if you are only 25% less busy than he/she was. Totally possible but won’t necessarily happen any faster than had you opened up your own clinic. Which begs the question, how much did you pay someone for the privilege of having to basically build your own practice any ways?

I have only lost ~25% of the patient load previous Dr. Had.

Did you “pay” for those patients in the buyout?

 

[heybrother]

(1) Stay strong / keep reading / keep reading about coding

(2) Call me crazy but there's somewhat of a small honeymoon in the beginning before you start operating. For whatever reason my practice couldn't get me credentialed for like 6 months. I had almost no stress during this time cause non-surgical patients are usually less stressful/have fewer problems.

(3) Never stop following your claims/surgeries/procedures/visits etc.

Insurance does some variation of the following for claims:
(a) adjusts them and then pays them - if you get paid 100% of something your fee schedule is too low
(b) adjusts them and now you have to get it from the patient - the best time to get this money is at a follow-up visit / strike while the iron is hot
(c) asks for more information - someone has to catch this - nothing is happening until the question gets answered - for example, I cleaned out an open fracture in the office. The insurance sent the patient demanding to know was it on the job etc. Gotta chase that.
(d) straight denies it - why is the question. Is it coding? Is it credentialing with insurance etc. Gotta figure out the why so that you can fight it, fix it, get it from the patient, or stop offering the service
( e ) pays part of it - doesn't pay part of it. Gotta find a way to make the case for the rest of the service.
(f) does nothing / won't respond / traps it in limbo hell - gotta find these cases. If they never send you a denial a lot of times nothing triggers and the bill just sits their rotting - sometimes its as simple as the # was wrong on the insurance, other times its just insurance treating us like trash
(g) pays it, instantly does a take back and claims insurance was not active (when it often was) - these have a tendency to fall through the cracks because they got paid if only for a moment. Did your office verify the insurance was activity the day of? Did the patient somehow change the plans or did the job do something, etc. Have to chase these asap because otherwise your EHR may just put it on some slow process alert where they won't ask you about it again for 3 months when in fact it either needs to immediately be battled or you need to bill the patient and strike while the iron is hot.

Can't stop chasing. There is something to be said for showing up early and checking everyone who is a follow-up to see did the billing go through.

(4) Do what is right but book/perform those surgeries as soon as possible. I don't force people into surgery. We discuss their expectations, what they want, does the recovery fit their life and then my office manager schedules. We still have too much attrition. Everyone's going to have a different opinion on this but I've watched myself lose cases as little things slipped through the cracks. Had a lapidus booked with a weird insurance - turned out my office botched the sign-up with the insurance. We had to push the case 1 week into the future, got the insurance issue fixed, and the patient spooked and ghosted us only to call back a month later and say she had decided not to do it. Beyond my control - she was excited in the room.

(5) Your EHR may have some sort of "calling system" but in my opinion someone in your office should still call every patient the day of to remind them to come to surgery. No computer can match your receptionist reminding them.

(6) My opinion again - if a new patient no shows or a follow that you intended to book surgery on no shows - don't let the receptionist cancel those. Call them back and try to reschedule the.

No one cares as much about your office and practice as you do. You may have great staff, but they will often still take the path of least resistance.

 

[heybrother]

I would encourage you when you respond to dtrack not to view his comments as negatives / a challenge / a reason to fight/be upset. Imagine that you are an executive of a company planning your next move and he is your lawyer/accountant asking - did we make the right play. If you were offered another identical deal right now to buy someone else's practices and "double your patients" - would you.

I say this as someone who started in a worse spot than you. I was an associate starting from scratch. I received theoretically about 8-10 new patients a day. Believe it or not I wrote a very similar post yours probably a year or 2 ago describing my excitement and the feeling that I was making great money and would soon be making even greater money still. I'll be killing it when I get to 20-30 is what I wrote. Now Covid didn't help my cause, but I can tell you its 2 years later and I'm in the 20-25 range still trying to make it perfect. I've figured some things out for myself. I'm still battling insurance plans I hate and I would like to perform more surgery. Weirdly I make more money than a friend of mine who sees double the patients which very clearly encapsulates the incredible danger of being an associate. I like that you have total control and I hope you'll find a way to put it to good use. I'm still having to explain to my office that yes - we should put any new patient who begs for a same day on my schedule and not schedule them 3 weeks out because by doing this we are both feeding our practice, our name, our revenue, and our reputation but also cannibalizing the other doctors in town. Someone else said this hilariously to me recently but part of your goal is to make the value of other doctors practices in town worth less. There are 2 old docs in my town in their upper 50s who are joyless/cheerless/pointless. I want them to close their doors without a buyer.

 

[NobodyDPM]

I finished residency this year. I started working at my practice mid July (bought from a retiring POD). Single practitioner.

I'm going to gross around 20k this month... and this is seeing around 10 to 15 pts a day with a mix of routine, sx candidates, wounds, bread and butter etc. Plus not seeing reimbursements for the 1st week of Aug. I have about 20 surgical patients lined up. Can't do elective sx due to covid surge in Texas.

It's amazing. I love working for myself. First week I worked about 12 to 16 hr days learning EMR, accounting, coding, etc. After a month I'm only working 8-12 hr days and still crazy busy with administration... but its starting to come together. I have only lost ~25% of the patient load previous Dr. Had.

Do yourself a favor and work for yourself.

If I have a consistant 30 pts a day x 4 days a week, averaging my $100-125 per pt (good coding, procedures, dispensing, etc). That's 600k+ easy. My overhead looking around 250k annual. 350k gross salary.

Don't listen to the toxic negativity within and without the podiatry community.

I just wanted to share my experience sand encourage others.

Congratulations on following your dream! Truly, that's amazing, and I wish you only prosperity and happiness.

If you ever have questions about general business, billing and coding, or just want to chat, please feel free to PM anytime.

Best of luck!

 

[619]

Congrats to OP!!

Just to add my 2 cents. I keep seeing people talk about attrition rate and what note. We are a specialists and the goal is to get new patients on your schedule and not hold on to old patients. I want my practice to be a revolving door, I want to see more new patients than follow-ups. For example, Patient comes in for heel pain, within 3 visits or less, they should be better and discharged to make room for more new patients. There is no reason to hold on to patients and string them along with unnecessary treatments. So obviously anyone who buys a practice would and should expect some "loss of old patients" but then I see it as a good thing because it makes space for "new patients" to get in which is where the money is. The old pods are struggling because they get comfortable with the diabetic nail care and fill up their schedules with nails and calluses. No reason to buy a practice and hold on to that. It's a blessing for the nails/calluses to go away and get the new patients in.

And regardless of how much OP paid for the practice, the decision he made is a million times better than being an associate for another pod. No doubt in his first year, he will take home 1.5x or 2x an associate salary and this is after taking out business expenses. In the 2nd year, 3rd year and beyond, an associates income will be peanuts compared to what OP will be making. I am saying this from a first hand experience.

The sky is the limit once you own your practice.

 

[HardRoadPaved]

It's a blessing for the nails/calluses to go away and get the new patients in.

While C&C is a small portion of my practice. I got tired of the cancels/no shows from patients scheduling 3 months out. I have no interest in retaining nails/calluses and I dont want to hear arguments like "its the visits that keeps the lights on." It doesnt when 11721 pays <$50 and its a whole ordeal just to get them in the chair. If there is a modicum of bad weather then, they are first to cancel. They can call me and I'll schedule them in at that point for their care.

(clarification: I am not saying all foot care is bad, but I was tired as an associate seeing tons perfectly healthy 65-85 year olds who wants medicare to pay for their nail trimming and preferably after a whirlpool)

 

[GreenHousePub]

It doesnt when 11721 pays <$50 and its a whole ordeal just to get them in the chair.

Too many people bill a 11721 when the patient doesn't really qualify. A 11720 along with the G0127 will actually pay more in my state.

 

[NobodyDPM]

Too many people bill a 11721 when the patient doesn't really qualify. A 11720 along with the G0127 will actually pay more in my state.

G0127 only if the nails are dystrophic, but not mycotic. If they aren't, you can bill a 11719 for non-dystrophic nail cutting.

 

[619]

They can call me and I'll schedule them in at that point for their care.

This is what In tell the few nail/callus patients that I have. Call us in 3-4 months when you are ready to get your nails cut again. I see perfectly abled patients in their 50s, 60s and even some in their 40s who their PCP send them over for diabetic foot check and to get their nails trimmed. I am now quick to discharge them after first visit and tell them to call us if they have any pain with their foot or ankle in the future.

No reason to fill up my schedule with people who have no real pathology. With the year coming to an end, this is the busiest time for doctors offices so I want to keep my time slots open for the good stuffs to be seen same day or same week. I don't think I need to see 30 patients a day to make a killing. Give me 20-24 max and I am good.

 

[air bud]

Speaking of nail care....how do you schedule? I was thinking of a power hour once a day. You can have nail care 10-11am that is it. Double book and 15 min slots.

 

[GreenHousePub]

Speaking of nail care....how do you schedule?

Often and frequently.
I've got the RRA cert and everything and I love nail care. Quick, easy and they are out. The more the better.

 

[NobodyDPM]

I find nail care to be the perfect gate way into the office. I get countless patients from happy nail care people.

 

[DYK343]

This is what In tell the few nail/callus patients that I have. Call us in 3-4 months when you are ready to get your nails cut again. I see perfectly abled patients in their 50s, 60s and even some in their 40s who their PCP send them over for diabetic foot check and to get their nails trimmed. I am now quick to discharge them after first visit and tell them to call us if they have any pain with their foot or ankle in the future.

No reason to fill up my schedule with people who have no real pathology. With the year coming to an end, this is the busiest time for doctors offices so I want to keep my time slots open for the good stuffs to be seen same day or same week. I don't think I need to see 30 patients a day to make a killing. Give me 20-24 max and I am good.

This is what I do in my practice and it has really opened the doors for a sports medicine practice.

The other foot docs in town are booked out 3-6 months with toenails and their staff turns down anything acute or gives long wait times to be seen. Those little old ladies toenails are not going to go away.

I am not booked because I dont really do much routine follow up care. Every day my schedule is full which is a benefit of a MSG. I have tons of referrals. If I look at next week its 50% full with mostly post ops and preops. Matrixectomy follow ups etc.

By the time I get to next week it will be full with new patients and pathology

It could backfire in private practice without a strong referral source I suppose. But thats how I run my practice and its been great.

 

[619]

This is what I do in my practice and it has really opened the doors for a sports medicine practice.

The other foot docs in town are booked out 3-6 months with toenails and their staff turns down anything acute or gives long wait times to be seen. Those little old ladies toenails are not going to go away.

I am not booked because I dont really do much routine follow up care. Every day my schedule is full which is a benefit of a MSG. I have tons of referrals. If I look at next week its 50% full with mostly post ops and preops. Matrixectomy follow ups etc.

By the time I get to next week it will be full with new patients and pathology

It could backfire in private practice without a strong referral source I suppose. But thats how I run my practice and its been great.

100% agree with your logic. When I first opened my practice in the middle of Covid, I was anxious and tried to hold on to routine nail care. However when I looked at my EOB and saw what routine nail care was paying, I might as well do door dash and make more in tips.
Currently, I get a lot of acute pathologies, patients who want to be seen same day or same week. Every week, I start with a light schedule and by the end of the week, it fills up with acute pathologies. That is why I said I want my practice to be a revolving door of new patient visits. You can't have that if you are booked out for months. People call around offices looking to get in for joint pain, heel pain, ingrown nail, ganglion cyst, acute injuries etc. I want to capture these new patients. I have no interest in seeing 30-40 patients a day when more than half is nail care.

 

[HardRoadPaved]

It could backfire in private practice without a strong referral source I suppose. But thats how I run my practice and its been great.

That is why I said I want my practice to be a revolving door of new patient visits. I have no interest in seeing 30-40 patients a day when more than half is nail care.

Preach!!!

A new heel pain patient with a visit, XR, and night splint will pay me no less than $250... You can have the 5 chip and clips and nail dust swarming the office. Also the best is when medicare C&C patients say "my regular podiatrist doesnt handle foot pain"

 

[air bud]

OMG YOU GUYS. I wanted technical details. Spread nailcare through out the day? Or one hour bust some fungies and move on so not taking up your schedule and canceling and screwing stuff up.

How do you structure your day?

 

[dtrack22]

OMG YOU GUYS. I wanted technical details. Spread nailcare through out the day? Or one hour bust some fungies and move on so not taking up your schedule and canceling and screwing stuff up.

How do you structure your day?

Depends on how easily you can template your schedule. It has to be pretty idiot proof for receptionists or it won’t work like you want it to. I prefer to have a max number of RFC patients per day so schedulers look at my schedule and if they see the 4 RFC spots booked then they move to the next day. If the scheduling software doesn’t make that easy for them, then I guess having an afternoon where you only do RFC once a week (for example) would also make it easy. You’ll end up cutting toenails outside of that if you accept new patients for “DM foot exams” which is PCP code for, the patient wants their toenails cut in my area. But for the most part you would have your one afternoon where you know all you’re doing is busting crumblies.

Being rural I’m unlikely to ever have my schedule so full that I can’t squeeze in a new patient within a day or two. So I don’t mind the RFC and I don’t mind scheduling them 3 months out. The old retired folks show up for that appointment because they literally have nothing else going on. I also have the ability to push those patients over to the wound care clinic (if I ever get overrun with toenails) where they will cut toenails, regardless if they can bill for it or not because they can still charge a facility fee, even for nursing visits.

Nails and calluses are worse for us wRVU folks than those in private practice. Don’t make money off of studies, DME, or self pay products they might need. Just your 0.5-something wRVU for the crumblies. It’s only equivalent to an established office visit if they have a few calluses which they don’t all have.

 

[NobodyDPM]

@air bud my apologies. I completely misunderstood your post and was being a jackass. Post deleted.

 

[ExperiencedDPM]

The OP omitted the cost of the practice and his monthly loan payout.

I would encourage the OP to let me know if he or she has any surgical coding issues. I am very well versed in the rules and not all the BS tricks to unbundle, etc.

I am paid by major insurers for my opinion and expertise in surgical coding. Take advantage of my offer and I can save you a lot of future aggravation.

 

[heybrother]

The OP omitted the cost of the practice and his monthly loan payout.

I would encourage the OP to let me know if he or she has any surgical coding issues. I am very well versed in the rules and not all the BS tricks to unbundle, etc.

I am paid by major insurers for my opinion and expertise in surgical coding. Take advantage of my offer and I can save you a lot of future aggravation.

A patient presents with a moderate-severe bunion. They have some degree of 1st MPJ remodelling/change ie. a larger medial eminence that is more than just out of position 1st ray, some dorsal catching spurring, a medial ridge cartilage remodelling from the valgus of the toe, etc. They are adamantly against a 1st MPJ fusion even though it would solve a lot of issues and uncertainties. You perform a 1st TMTJ joint fusion/lapidus/whatever realigning and close the IM. You open the 1st MPJ and extensively debride, clean-up ensuring 1st MPJ motion, removal prominences, ridges etc.

Let's put clinical judgement aside - because the motion at the 1st is never going to be like an unopened joint.

Your opinion - this codes as a lapidus, right?
Anything else:
ie. 1st TMTJ joint single fusion + Mcbride
or 1st TMTJ single joint fusion + Cheilectomy
or heck Lapidus + Cheilectomy
are all wrong?

Thanks in advance.

EDIT: I wrote this and you may already be responding or not. I've read your prior posts where you've essentially stated single fusion + McBride is dishonest. There's also another pretty decent coding answer online somewhere else where a guy points out calling a lapidus anything other than a lapidus really doesn't make sense - the lapidus code already perfectly describes the procedure. What I'm really referring to here is not trying to turn every lapidus into 2 procedures but those cases where I feel like I am doing 2 procedures. Cases where I'm working away in the 1st MPJ wishing wishing I could just do the 1st TMTJ fusion and get out.

 

[ExperiencedDPM]

A patient presents with a moderate-severe bunion. They have some degree of 1st MPJ remodelling/change ie. a larger medial eminence that is more than just out of position 1st ray, some dorsal catching spurring, a medial ridge cartilage remodelling from the valgus of the toe, etc. They are adamantly against a 1st MPJ fusion even though it would solve a lot of issues and uncertainties. You perform a 1st TMTJ joint fusion/lapidus/whatever realigning and close the IM. You open the 1st MPJ and extensively debride, clean-up ensuring 1st MPJ motion, removal prominences, ridges etc.

Let's put clinical judgement aside - because the motion at the 1st is never going to be like an unopened joint.

Your opinion - this codes as a lapidus, right?
Anything else:
ie. 1st TMTJ joint single fusion + Mcbride
or 1st TMTJ single joint fusion + Cheilectomy
or heck Lapidus + Cheilectomy
are all wrong?

Thanks in advance.

EDIT: I wrote this and you may already be responding or not. I've read your prior posts where you've essentially stated single fusion + McBride is dishonest. There's also another pretty decent coding answer online somewhere else where a guy points out calling a lapidus anything other than a lapidus really doesn't make sense - the lapidus code already perfectly describes the procedure. What I'm really referring to here is not trying to turn every lapidus into 2 procedures but those cases where I feel like I am doing 2 procedures. Cases where I'm working away in the 1st MPJ wishing wishing I could just do the 1st TMTJ fusion and get out.

A Lapidus or any other proprietary name is by definition a bunionectomy (with or without a sesamoidectomy) with a first metatarsal cuneiform arthrodesis.

No matter how you want to spin it, if your distal work is a “bunionectomy” and your proximal work is an arthrodesis of the first MCJ, it is a single code procedure.

I know ALL the arguments. All of them. It does not matter how many incisions you made. It doesn’t matter what hardware set you use. It’s doesn’t even matter if you tell me there is no CCI edit.

There IS a rule that you are obligated to bill to the highest specificity and if there’s a single code that describes the procedure, that is the correct code. Period.

I can tell you several large practices that just paid back a LOT of money for unbundling these codes. The insurers are not stupid and this type of unbundling is high up on their list.

Don’t do It and don’t listen to reps who tell you how to make more money. And for all of you who tell me “but I always get paid for it”………I assure you that your day is coming soon. Getting away with something is not an indicator that it’s correct. It just means you haven’t been caught, YET.

I drill this into my residents. Billing fraud pisses me off more than the guy who farts in an elevator as you are in getting and he’s getting out.

 

[heybrother]

A Lapidus or any other proprietary name is by definition a bunionectomy (with or without a sesamoidectomy) with a first metatarsal cuneiform arthrodesis.

No matter how you want to spin it, if your distal work is a “bunionectomy” and your proximal work is an arthrodesis of the first MCJ, it is a single code procedure.

I know ALL the arguments. All of them. It does not matter how many incisions you made. It doesn’t matter what hardware set you use. It’s doesn’t even matter if you tell me there is no CCI edit.

There IS a rule that you are obligated to bill to the highest specificity and if there’s a single code that describes the procedure, that is the correct code. Period.

I can tell you several large practices that just paid back a LOT of money for unbundling these codes. The insurers are not stupid and this type of unbundling is high up on their list.

Don’t do It and don’t listen to reps who tell you how to make more money. And for all of you who tell me “but I always get paid for it”………I assure you that your day is coming soon. Getting away with something is not an indicator that it’s correct. It just means you haven’t been caught, YET.

I drill this into my residents. Billing fraud pisses me off more than the guy who farts in an elevator as you are getting and he’s getting out.

Appreciate the feedback. You've talked about this before. I sat through one of the billing courses awhile back where my general feeling was a lot of the insanity was being shut down and most things are just becoming "the one procedure that describes it best"

 

[ExperiencedDPM]

Appreciate the feedback. You've talked about this before. I sat through one of the billing courses awhile back where my general feeling was a lot of the insanity was being shut down and most things are just becoming "the one procedure that describes it best"

I assure you that unfortunately the insanity is alive and well. I was called to review a provider who consistently bills 12 codes for a bunion procedure. He’s made me a lot of money reviewing his cases.

But he’s in deep doo doo now.

 

[heybrother]

I assure you that unfortunately the insanity is alive and well. I was called to review a provider who consistently bills 12 codes for a bunion procedure. He’s made me a lot of money reviewing his cases.

But he’s in deep doo doo now.

I've said this before elsewhere but I don't understand how they pull this off. I had a case when I first entered PP where my OM made it all sneaky to add an extra procedure. I was very clear with her all the shenanigans were really worth a 28285 and nothing more. Insurance denied it and we were paid less than we would have been if we'd done it kosher.

Some of the docs who were in a side group I trained with had a set of codes they used to turn a hammertoe and plantar plate repair - PIPJ fusion with implant, Weil, tendon rebalancing and something else I can't even remember into 4 procedures. They were hospital based and the RVUs were literally worth more than an ankle fracture. Its insane to me because if my partner bills a 28285 + Weil on the 2nd digit he gets denied half the time and either gets the Weil or the toe - not both.

Last of all, I hate Aetna but I feel like they came up with the ultimate solution for this. Full schedule 1st, half schedule 2nd, quarter schedule any procedure 3rd and on.

EDIT:
PIPJ fusion with implant
Weil Osteotomy
Open Reduction and Internal Fixation MPJ Dislocation
Capsulotendon balancing

For a 2nd digit hammertoe with plantar plate repair.

 

[Pronation]

I love that if you bill a lapidus code, then insurance won’t pay for the Akin.

 

[NobodyDPM]

I love that if you bill a lapidus code, then insurance won’t pay for the Akin.

They did many moons ago. Everyone was doing Akins. On every bunion procedure. Just to make more money. Sound familiar?

 

[Scrantonicity]

Just awesome how the more work you do, the less you get paid.

I can see it now. In 2025 there will just be one code...surgery on the FOOT. Flat fee. Global of 6 months.

 

[SouthPod7]

Just awesome how the more work you do, the less you get paid.

I can see it now. In 2025 there will just be one code...surgery on the FOOT. Flat fee.

I'm sure ABFAS/ACFAS will step in and demand that there will be two codes. One for "Foot Surgery" and one for "RRA Surgery." I wonder which one they will lobby to pay more?

 

[NobodyDPM]

Just awesome how the more work you do, the less you get paid.

I can see it now. In 2025 there will just be one code...surgery on the FOOT. Flat fee. Global of 6 months.

What's even more awesome is that medicine is the only profession where this applies. Need more? Pay more. Except for medical professionals. Also what other profession do you know of where you only get paid months after you provide the service? And only what someone else says you should be paid? What happened to a free market system?

 

[heybrother]

I am fascinated to hear that Akins are not being paid with another bunion code.

At the coding seminar 2 years ago they indicated the MUE of bunions was being dropped to 1. My partner kept doing bilateral Austins without issue. However, the other day my OM came to me wondering why the second Austin didn't get paid. It featured that vague MUE language about more procedures than expected or whatever. I thought - I guess that's finally here. Wonder if anyone else is seeing that.

The other day I sat down looking at the rates of our good payors because I want to go after our bad payors. The simple truth is if insurance paid me 100% of 2021 Medicare rate for E&M and imaging for most payors that would be a big improvement. Some in office CPT is fine ie. $110 for warts of $125 for an ulcer, but a lot of the rest ideally would be 150-155% of Medicare. ie. that puts injections into the $80ish range and matrixectomy at about $240. However, outpatient surgery really needs to be at least 190% of Medicare to ultimately be worthwhile and it would still be less than old school docs got paid. If Medicare took everything over tomorrow and I only got paid $550-650 or whatever for a 1st MPJ and lapidus for the rest of my career I would do what I think godfather suggested. I would drop my surgery days per month down to ...1-2 days and cram everything in that day.

 

[Scrantonicity]

What's even more awesome is that medicine is the only profession where this applies. Need more? Pay more. Except for medical professionals. Also what other profession do you know of where you only get paid months after you provide the service? And only what someone else says you should be paid? What happened to a free market system?

Right?? And sometimes (if you haven't been paying enough attention), you look back and realize you didn't get paid ANYTHING for that big complicated surgery after all. Someone in some office somewhere decided it wasn't "medically necessary" At least the patient is happy! Well, happy until they come back to your office a couple years later for something else and are told that they have a $1700 balance on their account. You'll never see them again haha.

Well, better luck next time. *books same surgery with patient's jobless neighbor

 

[HardRoadPaved]

Right?? And sometimes (if you haven't been paying enough attention), you look back and realize you didn't get paid ANYTHING for that big complicated surgery after all. Someone in some office somewhere decided it wasn't "medically necessary" At least the patient is happy! Well, happy until they come back to your office a couple years later for something else and are told that they have a $1700 balance on their account. You'll never see them again haha.

Well, better luck next time. *books same surgery with patient's jobless neighbor

This is why it is imperative to collect all copays and deductibles at time of service. At check in we are explicit with our policy to tell patients you have $XXXX deductible and today's visit will go towards that. If they dont want to see that large balance then adios! If the hospital next door to me is doing that along with all the labs and radiology centers then hell yea I am in.

You can literally run a cost estimator on the insurance web portals and give patient a print out.

 

[Scrantonicity]

This is why it is imperative to collect all copays and deductibles at time of service. At check in we are explicit with our policy to tell patients you have $XXXX deductible and today's visit will go towards that. If they dont want to see that large balance then adios! If the hospital next door to me is doing that along with all the labs and radiology centers then hell yea I am in.

You can literally run a cost estimator on the insurance web portals and give patient a print out.

Yeah, for sure...although some have said on these boards that even doing this is considered "breaking your contract". We do the same though, as I'm sure any successful practice does. It's just good businesss. With my example I was mainly talking about the back end (the part insurance is supposed to pay, assuming they are at all with deductibles being so high these days).

 

[NobodyDPM]

Collecting deductible amounts can be a tricky affair. They may have paid it already when having other services done, but it may not have posted yet on the insurer's portal. Then you may end up owing the patient. Just a thought.

 

[dtrack22]

Collecting deductible amounts can be a tricky affair. They may have paid it already when having other services done, but it may not have posted yet on the insurer's portal. Then you may end up owing the patient. Just a thought.

I found this to happen pretty rarely. It doesn’t matter if the patient has paid anything. Once a claim is submitted and their insurer determines a portion of the allowable goes to the deductible, the patient is credited with $XX of their deductible being met.

Patients who keep up with these things and insist they have hit their deductible can just be billed without collecting anything (it won’t happen that often). If you do collect and are wrong, then writing a check back to a handful of patients isn’t a big deal. It’s easier than trying to track down everything you are owed months after the service.

Or you can be a real podiatrist and offer the patient a 20% discount on anything they buy from your in-office shoe store, if they use that $ you owe them…

 

[Scrantonicity]

I found this to happen pretty rarely. It doesn’t matter if the patient has paid anything. Once a claim is submitted and their insurer determines a portion of the allowable goes to the deductible, the patient is credited with having $XX of their deductible as having been met.

Patients who keep up with these things and insist they have hit their deductible can just be billed without collecting anything (it won’t happen that often). If you do collect and are wrong, then writing a check back to a handful of patients isn’t a big deal. It’s easier than trying to track down everything you are owed months after the service.

Or you can be a real podiatrist and offer the patient a 20% discount on anything they buy from your in-office shoe store, if they use that $ you owe them…

I was just typing this same reply when you posted. Minus the "in store credit" part. That's genius haha

"Look....we owe you $200. I'm just going to give you 2 jars of our special mix of Urea 40% cream and 3 pairs of Powersteps, mmkay?"

 

[NobodyDPM]

I found this to happen pretty rarely. It doesn’t matter if the patient has paid anything. Once a claim is submitted and their insurer determines a portion of the allowable goes to the deductible, the patient is credited with having $XX of their deductible as having been met.

Patients who keep up with these things and insist they have hit their deductible can just be billed without collecting anything (it won’t happen that often). If you do collect and are wrong, then writing a check back to a handful of patients isn’t a big deal. It’s easier than trying to track down everything you are owed months after the service.

Or you can be a real podiatrist and offer the patient a 20% discount on anything they buy from your in-office shoe store, if they use that $ you owe them…

I certainly don't disagree. Except that last part, LOL.

A little caution goes a long way. That's all.

 

[GreenGreen]

Congrats! There is something definitely nice about getting the reigns of a practice if the original owner had a similar mindset and remaining staff is ready to work for you. 15 patients per day x 5 days x 4 weeks = 300 visits. 20k/300 = $66/ visit.... keep aiming higher!

Do you mind sharing your general buy out terms?

Old practitioner was very generous. We also saw eye to eye on many things. I saw his taxes and accounting documents and he grossed over 300k 3 years straight working about 25hrs a week.

200k buyout 50k down and 7 year contract with 3% interest payments made quarterly. Payments work out to be just under 6k a quarter. Overall cost will be ~215k

Congrats! There is something definitely nice about getting the reigns of a practice if the original owner had a similar mindset and remaining staff is ready to work for you. 15 patients per day x 5 days x 4 weeks = 300 visits. 20k/300 = $66/ visit.... keep aiming higher!

Do you mind sharing your general buy out terms?

 

[GreenGreen]

A 200k buyout from a well respected doc. 25 years in same location and able to bill under his institution NPI immediately. Staff stayed. Overhead is now easily covered.

So you aren’t covering your overhead yet?


If you are at ~13 patients per day, and that’s only a 25% decrease from the previous owner, then you’ll need to grow by over 100% to get to the above figures. The previous owner wasn’t even doing that if you are only 25% less busy than he/she was. Totally possible but won’t necessarily happen any faster than had you opened up your own clinic. Which begs the question, how much did you pay someone for the privilege of having to basically build your own practice any ways?



Did you “pay” for those patients in the buyout?

A 200k buyout from a well respected doc. 25 years in same location and able to bill under his institution NPI immediately. Staff stayed. Overhead is now easily covered. Getting busier now.

The value for me was being able to bill insurance right off the bat, to have a good referral source, and to avoid the massive time investment starting from scratch.

Not everyone will agree with my investment. To me this was worth it and I'm very satisfied.

 

[GreenGreen]

(1) Stay strong / keep reading / keep reading about coding

(2) Call me crazy but there's somewhat of a small honeymoon in the beginning before you start operating. For whatever reason my practice couldn't get me credentialed for like 6 months. I had almost no stress during this time cause non-surgical patients are usually less stressful/have fewer problems.

(3) Never stop following your claims/surgeries/procedures/visits etc.

Insurance does some variation of the following for claims:
(a) adjusts them and then pays them - if you get paid 100% of something your fee schedule is too low
(b) adjusts them and now you have to get it from the patient - the best time to get this money is at a follow-up visit / strike while the iron is hot
(c) asks for more information - someone has to catch this - nothing is happening until the question gets answered - for example, I cleaned out an open fracture in the office. The insurance sent the patient demanding to know was it on the job etc. Gotta chase that.
(d) straight denies it - why is the question. Is it coding? Is it credentialing with insurance etc. Gotta figure out the why so that you can fight it, fix it, get it from the patient, or stop offering the service
( e ) pays part of it - doesn't pay part of it. Gotta find a way to make the case for the rest of the service.
(f) does nothing / won't respond / traps it in limbo hell - gotta find these cases. If they never send you a denial a lot of times nothing triggers and the bill just sits their rotting - sometimes its as simple as the # was wrong on the insurance, other times its just insurance treating us like trash
(g) pays it, instantly does a take back and claims insurance was not active (when it often was) - these have a tendency to fall through the cracks because they got paid if only for a moment. Did your office verify the insurance was activity the day of? Did the patient somehow change the plans or did the job do something, etc. Have to chase these asap because otherwise your EHR may just put it on some slow process alert where they won't ask you about it again for 3 months when in fact it either needs to immediately be battled or you need to bill the patient and strike while the iron is hot.

Can't stop chasing. There is something to be said for showing up early and checking everyone who is a follow-up to see did the billing go through.

(4) Do what is right but book/perform those surgeries as soon as possible. I don't force people into surgery. We discuss their expectations, what they want, does the recovery fit their life and then my office manager schedules. We still have too much attrition. Everyone's going to have a different opinion on this but I've watched myself lose cases as little things slipped through the cracks. Had a lapidus booked with a weird insurance - turned out my office botched the sign-up with the insurance. We had to push the case 1 week into the future, got the insurance issue fixed, and the patient spooked and ghosted us only to call back a month later and say she had decided not to do it. Beyond my control - she was excited in the room.

(5) Your EHR may have some sort of "calling system" but in my opinion someone in your office should still call every patient the day of to remind them to come to surgery. No computer can match your receptionist reminding them.

(6) My opinion again - if a new patient no shows or a follow that you intended to book surgery on no shows - don't let the receptionist cancel those. Call them back and try to reschedule the.

No one cares as much about your office and practice as you do. You may have great staff, but they will often still take the path of least resistance.

Thanks. And I totally agree with #5 even though my front desk wants me to automate.

I would encourage you when you respond to dtrack not to view his comments as negatives / a challenge / a reason to fight/be upset. Imagine that you are an executive of a company planning your next move and he is your lawyer/accountant asking - did we make the right play. If you were offered another identical deal right now to buy someone else's practices and "double your patients" - would you.

I say this as someone who started in a worse spot than you. I was an associate starting from scratch. I received theoretically about 8-10 new patients a day. Believe it or not I wrote a very similar post yours probably a year or 2 ago describing my excitement and the feeling that I was making great money and would soon be making even greater money still. I'll be killing it when I get to 20-30 is what I wrote. Now Covid didn't help my cause, but I can tell you its 2 years later and I'm in the 20-25 range still trying to make it perfect. I've figured some things out for myself. I'm still battling insurance plans I hate and I would like to perform more surgery. Weirdly I make more money than a friend of mine who sees double the patients which very clearly encapsulates the incredible danger of being an associate. I like that you have total control and I hope you'll find a way to put it to good use. I'm still having to explain to my office that yes - we should put any new patient who begs for a same day on my schedule and not schedule them 3 weeks out because by doing this we are both feeding our practice, our name, our revenue, and our reputation but also cannibalizing the other doctors in town. Someone else said this hilariously to me recently but part of your goal is to make the value of other doctors practices in town worth less. There are 2 old docs in my town in their upper 50s who are joyless/cheerless/pointless. I want them to close their doors without a buyer.

Thanks. I appreciate advice, and I'm flexible to listen to anyone's point of view so no worries. Best of luck.

 

[GreenGreen]

Congrats to OP!!

Just to add my 2 cents. I keep seeing people talk about attrition rate and what note. We are a specialists and the goal is to get new patients on your schedule and not hold on to old patients. I want my practice to be a revolving door, I want to see more new patients than follow-ups. For example, Patient comes in for heel pain, within 3 visits or less, they should be better and discharged to make room for more new patients. There is no reason to hold on to patients and string them along with unnecessary treatments. So obviously anyone who buys a practice would and should expect some "loss of old patients" but then I see it as a good thing because it makes space for "new patients" to get in which is where the money is. The old pods are struggling because they get comfortable with the diabetic nail care and fill up their schedules with nails and calluses. No reason to buy a practice and hold on to that. It's a blessing for the nails/calluses to go away and get the new patients in.

And regardless of how much OP paid for the practice, the decision he made is a million times better than being an associate for another pod. No doubt in his first year, he will take home 1.5x or 2x an associate salary and this is after taking out business expenses. In the 2nd year, 3rd year and beyond, an associates income will be peanuts compared to what OP will be making. I am saying this from a first hand experience.

The sky is the limit once you own your practice.

Thanks. I kind of know what you mean...I tell my patients very candidly that I try to work myself out of a job, cause that means I did a good job. I'm already siphoning patients from a nearby mill of a practice and they are very grateful.

 

[NobodyDPM]

A 200k buyout from a well respected doc. 25 years in same location and able to bill under his institution NPI immediately. Staff stayed. Overhead is now easily covered.

A 200k buyout from a well respected doc. 25 years in same location and able to bill under his institution NPI immediately. Staff stayed. Overhead is now easily covered. Getting busier now.

The value for me was being able to bill insurance right off the bat, to have a good referral source, and to avoid the massive time investment starting from scratch.

Not everyone will agree with my investment. To me this was worth it and I'm very satisfied.

Bold mine.

That's all that matters. I wish you nothing but success and happiness.

 

[GreenGreen]

While C&C is a small portion of my practice. I got tired of the cancels/no shows from patients scheduling 3 months out. I have no interest in retaining nails/calluses and I dont want to hear arguments like "its the visits that keeps the lights on." It doesnt when 11721 pays <$50 and its a whole ordeal just to get them in the chair. If there is a modicum of bad weather then, they are first to cancel. They can call me and I'll schedule them in at that point for their care.

(clarification: I am not saying all foot care is bad, but I was tired as an associate seeing tons perfectly healthy 65-85 year olds who wants medicare to pay for their nail trimming and preferably after a whirlpool)

Totally understand. I only take Medicare and good non marketplace insurance (bcbs and the like). No medicaid. I'm very fortunate that my no show rate/same day reschedule averages 1 to 2 a day. My patient population is very punctual... which helps immensely.

I'm a bit of a stickler on rules. I follow CMS rules from my MAC very closely. I have it all printed and on my desk which is kinda strange but... I ask them: are you in pain when you walk with long nails? Etc etc, and document to meet criteria. Q8 of course is easy. C/C seem to rarely give issues but then again (don't tell him I said anything) I wrote my directors notes for 3 years. 🤷‍♂️

 

[NobodyDPM]

Totally understand. I only take Medicare and good non marketplace insurance (bcbs and the like). No medicaid. I'm very fortunate that my no show rate/same day reschedule averages 1 to 2 a day. My patient population is very punctual... which helps immensely.

I'm a bit of a stickler on rules. I follow CMS rules from my MAC very closely. I have it all printed and on my desk which is kinda strange but... I ask them: are you in pain when you walk with long nails? Etc etc, and document to meet criteria. Q8 of course is easy. C/C seem to rarely give issues but then again (don't tell him I said anything) I wrote my directors notes for 3 years. 🤷‍♂️

Do you do DME and Diabetic shoes? Great way to increase your revenue.

 

[GreenGreen]

A patient presents with a moderate-severe bunion. They have some degree of 1st MPJ remodelling/change ie. a larger medial eminence that is more than just out of position 1st ray, some dorsal catching spurring, a medial ridge cartilage remodelling from the valgus of the toe, etc. They are adamantly against a 1st MPJ fusion even though it would solve a lot of issues and uncertainties. You perform a 1st TMTJ joint fusion/lapidus/whatever realigning and close the IM. You open the 1st MPJ and extensively debride, clean-up ensuring 1st MPJ motion, removal prominences, ridges etc.

Let's put clinical judgement aside - because the motion at the 1st is never going to be like an unopened joint.

Your opinion - this codes as a lapidus, right?
Anything else:
ie. 1st TMTJ joint single fusion + Mcbride
or 1st TMTJ single joint fusion + Cheilectomy
or heck Lapidus + Cheilectomy
are all wrong?

Thanks in advance.

EDIT: I wrote this and you may already be responding or not. I've read your prior posts where you've essentially stated single fusion + McBride is dishonest. There's also another pretty decent coding answer online somewhere else where a guy points out calling a lapidus anything other than a lapidus really doesn't make sense - the lapidus code already perfectly describes the procedure. What I'm really referring to here is not trying to turn every lapidus into 2 procedures but those cases where I feel like I am doing 2 procedures. Cases where I'm working away in the 1st MPJ wishing wishing I could just do the 1st TMTJ fusion and get out.

My opinion is if a patient doesn't agree with my procedure, they can go get a 2nd opinion or go elsewhere. I explain the reasoning of my procedures very well and everything I do is backed by literature.

 

[GreenGreen]

Do you do DME and Diabetic shoes? Great way to increase your revenue.

In the works. PTAN should come soon

 

[Feli]

...The value for me was being able to bill insurance right off the bat, to have a good referral source, and to avoid the massive time investment starting from scratch.

Not everyone will agree with my investment. To me this was worth it and I'm very satisfied.

Correct. I concur with that 100%.

There is value in buying out... no doubt about it. Even if you are just buying some crummy equipment and location that area residents know is "foot doctor," that is slightly valuable. If you got a reputation and handoff goodwill with area PCPs referring from your seller, that is somewhat to significantly valuable - depending on how area payers are, how tough the area would have been to break into, etc. You made the best move for you. It is good to be able to focus on getting/training/keeping good staff, learning prac mgmt, etc instead of just devoting a huge amount of your time to marketing immediately since you need to do that just to keep the lights on. No question.

 

[ExperiencedDPM]

I am fascinated to hear that Akins are not being paid with another bunion code.

At the coding seminar 2 years ago they indicated the MUE of bunions was being dropped to 1. My partner kept doing bilateral Austins without issue. However, the other day my OM came to me wondering why the second Austin didn't get paid. It featured that vague MUE language about more procedures than expected or whatever. I thought - I guess that's finally here. Wonder if anyone else is seeing that.

The other day I sat down looking at the rates of our good payors because I want to go after our bad payors. The simple truth is if insurance paid me 100% of 2021 Medicare rate for E&M and imaging for most payors that would be a big improvement. Some in office CPT is fine ie. $110 for warts of $125 for an ulcer, but a lot of the rest ideally would be 150-155% of Medicare. ie. that puts injections into the $80ish range and matrixectomy at about $240. However, outpatient surgery really needs to be at least 190% of Medicare to ultimately be worthwhile and it would still be less than old school docs got paid. If Medicare took everything over tomorrow and I only got paid $550-650 or whatever for a 1st MPJ and lapidus for the rest of my career I would do what I think godfather suggested. I would drop my surgery days per month down to ...1-2 days and cram everything in that day.

Look up an “Akin”. It’s CPT code 28310 (CPT 28298 is a bunionectomy with an Akin). If you look up 28310 you will see it’s designated as a “separate” procedure which denotes it should not be billed with another procedure for the same pathology at the same anatomical location.