Trends in Private Practice Podiatry

[MicroPod]

Hi,

I have been reading through the forums for quite a while, but this is my first time posting. I wanted to see if I could get some opinions/experiences from current Podiatrists in private practice.

I personally know three podiatrists (they make up a pod group), and they have expressed the opinion that the "government" is making it increasingly harder and less profitable to be in private practice. For example, one of the podiatrists told me that he makes 40% less than what he used to make about 15 years ago. I have also seen the struggle between them and the insurance companies. In many cases, it is the insurance company, and not the doctor deciding what can and cannot be done for a patient (unless they want to pay out of pocket, which many people do not).

These guys still make a very good living, so it is not like it is the end of the world for them or anything like that. I guess the questions I am asking are:

1. Will the trend of decreased compensation for podiatrists (and other healthcare practitioners) continue?

2. Will the trend of increasing insurance companies presence in treating patients continue?

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[bunNfxr]

I closed my office and moved my family to become an employee, due to regulations and changing business landscape that accompanies these regulations. Regulations and factors to consider
1. Student debt and business startup costs are much higher than 10 years ago and dramatically higher than 20 years ago. Which means you cannot take out the equivalent of a fancy car loan to start up a practice. Its big money to put up while waiting for your practice to "build".
2. Meaningful Use now MACRA regulations require about 30-50 thousand dollars into medical records (software and servers) over the first 5 years (2-10K thereafter), whereas it would have cost you 500 bucks (Maybe) for files and cabinets 20 years ago, and affordable software options were available before everyone was required to have it. These requirements reduce the number of patients you see, and force you to focus on satisfying "quality" measures and reporting them. But actually take away from your ability to treat patients efficiently and effectively.
3. ACO organization: This is still a developing story, but basically you will have to join to see Medicare patients (And private insurance companies are expected to follow suit). The Hospital will run it and then determine how much work you get based on how Medicare determines your value by nonsensical metrics and computations.
4. To meet the above regulations most primary care doctors and multispecialty groups are hiring many nurse practitioners and physician assistants to do much of what doctors once did, while paying them less than a physician. In many cases they are keeping ingrown toenails, wounds and heel pain in their offices rather than referring these "simple" things out. This translates into less available work.
5. Diabetic shoes are difficult to get paid on and many carriers are doing prepayment audits. This essentially translates to them require you to pay for and dispense DM shoes, then denying legitimate claims and making it cost prohibitive to appeal due to time and financial costs being more than you can recover when you win the appeals. Before I stopped dispensing I was told I would have to present In person to appeal my outstanding claims in a city 90 miles away. I was using a service to "guarantee" than my documentation would ensure proper payment before shoes were dispensed. it worked for about 7 years but the rules shifted to impossible standards. They require identical language in the primary care doctors note as the podiatrist note regarding the need for DM shoes.
6. This is not new, but the recent increase in hospital employed DPMs creates an issue in that: first, they have a huge marketing budget, 2nd they get paid facility fees to recoup money that you would could not tap as a competing business. So weather they debride toenails or give a cortisone shot for heel pain, they are getting about a $150 facility fee that you can't get.
7. ACA plans have converted many or most patients to high deductible (5-10,000 dollar) plans so that many patients have opted to refrain from elective surgeries and live with there bunions , hammertoes, heel pains etc. This is podiatry bread and butter. When they do agree to surgery you often have to make long term payment arrangements trickling in money slowly whereas 5 years ago you would have been paid by the insurance company (Poorly but within 90 days).
8. Again though not new, insurance companies use "claw backs" more frequently than 5-10 years ago. This is where people sign up for the ACA online and pay for their first month. They then proceed to see you the doctor but realize they cannot afford the massive deductibles and outrageous premiums of their newly found insurance so they stop paying for their insurance. Meanwhile, the insurance company pays you for seeing the patient and fixing their ingrown toenail. Because the patient saw you after the paid month but has 90 days to pay for the second month. The insurance company takes the money back from you by subtracting it from your next check for other services. Then you bill the patient that could not afford their insurance and they either ignore the bill or send you a letter from their bankruptcy attorney absolving them of their debt to you.
9. Commercial real estate rents and payments --though leveled off, is still about 30-50% more than 10 years ago.
10. HIPPA regulations though not commonly enforced, the mere threat of a $10,000 fine per violation per workstation per day is enough to make sure you are in compliance. This may not sound like a big deal but here is an example of something you are probably not considering. When Microsoft sunsets an OS all the products for that OS go unsupported and updates including security updates cease. Technically you need to upgrade your operating systems. In my case I had a sever with SQL on it which was the database used by my EMR. In order to upgrade, I would need to buy the new SQL ($1100), purchase a new server to accommodate Windows 8/10 architecture and then transfer all my data to the new server. If not compliant I would fail MACRA compliance above and be penalized. If cited god forbid, I would be fined on each workstation daily until the problem was fully fixed.
11. The rise of co- insurance. This used to be minor but is now fairly common. This is another way to pass the expense on to the patient. This again means you have to chase patients for the bill and parses the payment up so that you get part of the payment as a co pay, part as what the insurance pays and then after the claim gets processed you have to go bill the patient again. The amounts are frequently in the 70 cents to 10 dollar range so that billing the patient cost more in postage than you will collect, but the cumulative effect is many thousands of dollars a year in lost revenue if you do not collect it.
12. If you are just out of school and think that you are going to practice without selling tolnaftate as though it the latest greatest thing; orthotics at prices you would scoff at; poorly scientifically supported treatments for heel pain and nail fungus for cash, then you may struggle to make enough from insurance covered services to compensate for what many practices are doing to keep their doors open.
These are just a few issues off the top of my head, but I think they are the major differences between now and 10 years ago

 

[Podstar]

I closed my office and moved my family to become an employee, due to regulations and changing business landscape that accompanies these regulations. Regulations and factors to consider
1. Student debt and business startup costs are much higher than 10 years ago and dramatically higher than 20 years ago. Which means you cannot take out the equivalent of a fancy car loan to start up a practice. Its big money to put up while waiting for your practice to "build".
2. Meaningful Use now MACRA regulations require about 30-50 thousand dollars into medical records (software and servers) over the first 5 years (2-10K thereafter), whereas it would have cost you 500 bucks (Maybe) for files and cabinets 20 years ago, and affordable software options were available before everyone was required to have it. These requirements reduce the number of patients you see, and force you to focus on satisfying "quality" measures and reporting them. But actually take away from your ability to treat patients efficiently and effectively.
3. ACO organization: This is still a developing story, but basically you will have to join to see Medicare patients (And private insurance companies are expected to follow suit). The Hospital will run it and then determine how much work you get based on how Medicare determines your value by nonsensical metrics and computations.
4. To meet the above regulations most primary care doctors and multispecialty groups are hiring many nurse practitioners and physician assistants to do much of what doctors once did, while paying them less than a physician. In many cases they are keeping ingrown toenails, wounds and heel pain in their offices rather than referring these "simple" things out. This translates into less available work.
5. Diabetic shoes are difficult to get paid on and many carriers are doing prepayment audits. This essentially translates to them require you to pay for and dispense DM shoes, then denying legitimate claims and making it cost prohibitive to appeal due to time and financial costs being more than you can recover when you win the appeals. Before I stopped dispensing I was told I would have to present In person to appeal my outstanding claims in a city 90 miles away. I was using a service to "guarantee" than my documentation would ensure proper payment before shoes were dispensed. it worked for about 7 years but the rules shifted to impossible standards. They require identical language in the primary care doctors note as the podiatrist note regarding the need for DM shoes.
6. This is not new, but the recent increase in hospital employed DPMs creates an issue in that: first, they have a huge marketing budget, 2nd they get paid facility fees to recoup money that you would could not tap as a competing business. So weather they debride toenails or give a cortisone shot for heel pain, they are getting about a $150 facility fee that you can't get.
7. ACA plans have converted many or most patients to high deductible (5-10,000 dollar) plans so that many patients have opted to refrain from elective surgeries and live with there bunions , hammertoes, heel pains etc. This is podiatry bread and butter. When they do agree to surgery you often have to make long term payment arrangements trickling in money slowly whereas 5 years ago you would have been paid by the insurance company (Poorly but within 90 days).
8. Again though not new, insurance companies use "claw backs" more frequently than 5-10 years ago. This is where people sign up for the ACA online and pay for their first month. They then proceed to see you the doctor but realize they cannot afford the massive deductibles and outrageous premiums of their newly found insurance so they stop paying for their insurance. Meanwhile, the insurance company pays you for seeing the patient and fixing their ingrown toenail. Because the patient saw you after the paid month but has 90 days to pay for the second month. The insurance company takes the money back from you by subtracting it from your next check for other services. Then you bill the patient that could not afford their insurance and they either ignore the bill or send you a letter from their bankruptcy attorney absolving them of their debt to you.
9. Commercial real estate rents and payments --though leveled off, is still about 30-50% more than 10 years ago.
10. HIPPA regulations though not commonly enforced, the mere threat of a $10,000 fine per violation per workstation per day is enough to make sure you are in compliance. This may not sound like a big deal but here is an example of something you are probably not considering. When Microsoft sunsets an OS all the products for that OS go unsupported and updates including security updates cease. Technically you need to upgrade your operating systems. In my case I had a sever with SQL on it which was the database used by my EMR. In order to upgrade, I would need to buy the new SQL ($1100), purchase a new server to accommodate Windows 8/10 architecture and then transfer all my data to the new server. If not compliant I would fail MACRA compliance above and be penalized. If cited god forbid, I would be fined on each workstation daily until the problem was fully fixed.
11. The rise of co- insurance. This used to be minor but is now fairly common. This is another way to pass the expense on to the patient. This again means you have to chase patients for the bill and parses the payment up so that you get part of the payment as a co pay, part as what the insurance pays and then after the claim gets processed you have to go bill the patient again. The amounts are frequently in the 70 cents to 10 dollar range so that billing the patient cost more in postage than you will collect, but the cumulative effect is many thousands of dollars a year in lost revenue if you do not collect it.
12. If you are just out of school and think that you are going to practice without selling tolnaftate as though it the latest greatest thing; orthotics at prices you would scoff at; poorly scientifically supported treatments for heel pain and nail fungus for cash, then you may struggle to make enough from insurance covered services to compensate for what many practices are doing to keep their doors open.
These are just a few issues off the top of my head, but I think they are the major differences between now and 10 years ago

Thank you for this!! Eye opening for us hoping to enter the profession!

 

[Nervous Pre-Pod]

I closed my office and moved my family to become an employee, due to regulations and changing business landscape that accompanies these regulations. Regulations and factors to consider
1. Student debt and business startup costs are much higher than 10 years ago and dramatically higher than 20 years ago. Which means you cannot take out the equivalent of a fancy car loan to start up a practice. Its big money to put up while waiting for your practice to "build".
2. Meaningful Use now MACRA regulations require about 30-50 thousand dollars into medical records (software and servers) over the first 5 years (2-10K thereafter), whereas it would have cost you 500 bucks (Maybe) for files and cabinets 20 years ago, and affordable software options were available before everyone was required to have it. These requirements reduce the number of patients you see, and force you to focus on satisfying "quality" measures and reporting them. But actually take away from your ability to treat patients efficiently and effectively.
3. ACO organization: This is still a developing story, but basically you will have to join to see Medicare patients (And private insurance companies are expected to follow suit). The Hospital will run it and then determine how much work you get based on how Medicare determines your value by nonsensical metrics and computations.
4. To meet the above regulations most primary care doctors and multispecialty groups are hiring many nurse practitioners and physician assistants to do much of what doctors once did, while paying them less than a physician. In many cases they are keeping ingrown toenails, wounds and heel pain in their offices rather than referring these "simple" things out. This translates into less available work.
5. Diabetic shoes are difficult to get paid on and many carriers are doing prepayment audits. This essentially translates to them require you to pay for and dispense DM shoes, then denying legitimate claims and making it cost prohibitive to appeal due to time and financial costs being more than you can recover when you win the appeals. Before I stopped dispensing I was told I would have to present In person to appeal my outstanding claims in a city 90 miles away. I was using a service to "guarantee" than my documentation would ensure proper payment before shoes were dispensed. it worked for about 7 years but the rules shifted to impossible standards. They require identical language in the primary care doctors note as the podiatrist note regarding the need for DM shoes.
6. This is not new, but the recent increase in hospital employed DPMs creates an issue in that: first, they have a huge marketing budget, 2nd they get paid facility fees to recoup money that you would could not tap as a competing business. So weather they debride toenails or give a cortisone shot for heel pain, they are getting about a $150 facility fee that you can't get.
7. ACA plans have converted many or most patients to high deductible (5-10,000 dollar) plans so that many patients have opted to refrain from elective surgeries and live with there bunions , hammertoes, heel pains etc. This is podiatry bread and butter. When they do agree to surgery you often have to make long term payment arrangements trickling in money slowly whereas 5 years ago you would have been paid by the insurance company (Poorly but within 90 days).
8. Again though not new, insurance companies use "claw backs" more frequently than 5-10 years ago. This is where people sign up for the ACA online and pay for their first month. They then proceed to see you the doctor but realize they cannot afford the massive deductibles and outrageous premiums of their newly found insurance so they stop paying for their insurance. Meanwhile, the insurance company pays you for seeing the patient and fixing their ingrown toenail. Because the patient saw you after the paid month but has 90 days to pay for the second month. The insurance company takes the money back from you by subtracting it from your next check for other services. Then you bill the patient that could not afford their insurance and they either ignore the bill or send you a letter from their bankruptcy attorney absolving them of their debt to you.
9. Commercial real estate rents and payments --though leveled off, is still about 30-50% more than 10 years ago.
10. HIPPA regulations though not commonly enforced, the mere threat of a $10,000 fine per violation per workstation per day is enough to make sure you are in compliance. This may not sound like a big deal but here is an example of something you are probably not considering. When Microsoft sunsets an OS all the products for that OS go unsupported and updates including security updates cease. Technically you need to upgrade your operating systems. In my case I had a sever with SQL on it which was the database used by my EMR. In order to upgrade, I would need to buy the new SQL ($1100), purchase a new server to accommodate Windows 8/10 architecture and then transfer all my data to the new server. If not compliant I would fail MACRA compliance above and be penalized. If cited god forbid, I would be fined on each workstation daily until the problem was fully fixed.
11. The rise of co- insurance. This used to be minor but is now fairly common. This is another way to pass the expense on to the patient. This again means you have to chase patients for the bill and parses the payment up so that you get part of the payment as a co pay, part as what the insurance pays and then after the claim gets processed you have to go bill the patient again. The amounts are frequently in the 70 cents to 10 dollar range so that billing the patient cost more in postage than you will collect, but the cumulative effect is many thousands of dollars a year in lost revenue if you do not collect it.
12. If you are just out of school and think that you are going to practice without selling tolnaftate as though it the latest greatest thing; orthotics at prices you would scoff at; poorly scientifically supported treatments for heel pain and nail fungus for cash, then you may struggle to make enough from insurance covered services to compensate for what many practices are doing to keep their doors open.
These are just a few issues off the top of my head, but I think they are the major differences between now and 10 years ago

Thanks for all of this great information! It seems like most of the issues have to do with working in a private practice. Would you recommend trying to get a job as a hospital podiatrist?

 

[JewOnThis]

I for one actually considered buying out a practice at one point, but after looking at how things were going with podiatry I decided not to. There are some pros in owning a business, but way too many cons.

I hate to say it, but this profession is trending for the worse. We are our worst enemies. I am sure most practicing podiatrists would agree with me.

 

[JewOnThis]

Thanks for all of this great information! It seems like most of the issues have to do with working in a private practice. Would you recommend trying to get a job as a hospital podiatrist?

Pre-pods need to realize that 95% of graduating podiatrists will end up in private practice.

Yes, I do recommend joining a hospital. Keep in mind, there are A LOT of qualified podiatrists looking for hospital positions.

 

[Cranjis McBasketball]

Any job in healthcare is trending for the worse. America is in a health crisis with our lifestyle which is forcing insurances to raise premiums/deductibles or cut down on reimbursements to be able to make a profit. Basically, Americans are becoming more expensive patients as we develop less healthy habits.

 

[bunNfxr]

On this subject:
1. ) Don't get wrapped up in the doctors make bad businessmen argument. That is not the problem. You can provide better value by providing more time and better quality of service and even better pricing and value on whatever products are sold in your office(like orthotics) and that will not increase your revenue. When this is said there is an implied message to sell more surgery and more stuff. But healthcare has to be about what is best for the patient. Unfortunately, you will be paid the same if spend 20 minutes on a pre operative discussion of post surgical implications or if you hand them a sheet of paper and walk out of the room. It even sells today as good doctor because overbooked and has no time.

2.) There are groups that are doing fine and practicing to high standards. But, Something has to give in this environment. So when looking into a practice look at what is compromised in order to practice close to the way you want. Some things are worth giving up maybe condensing the 30 minute discussions. This may mean cutting out sports med as they require a lot of your time. If practices are managing well now, they are most likely skipping the MACRA/Meaningful Use reward/ penalties. This may not be viable in a few years (2019 is the tentative must play date). You may just be guessing at how health care gets redesigned. If they are seeing 40 pts a day and meeting MACRA/ MU they either have tremendous support staff and expenses and/or they are just checking the boxes and hoping they don't get audited. I was audited and passed, but they do dig. And, before the last administration left they increased funding for more Audits. So expect to see more penalties or jail time if your practice is fudging numbers.

3.) Healthcare professions are doing fine. But PAs, NPs, and CRNAs are probably the best and most secure deal for the time being. Podiatry has a restricted license that limits career mobility. As primary care closes with increased numbers of nurse practitioners, PCPs can move to Urgent care centers, sleep study centers, HBO / wound centers, Testosterone clinics etc. Podiatry does not have that flexibility. You have to make it work. This may mean working for a hospital, or shifting to more non-insurance based care in the office. But that closes the door on certain expectations. If you want to be your own boss, you may not be doing surgery in a few years. If you want to do surgery you may be working for a hospital, ortho or multispecialty group in order to secure referrals for the kind of work you want. I have seen other specialties wiped out of practice by hospital buyouts and PA replacements. But I also saw those doctors land on their feet about a month later within a one hour commute. Maybe I chickened out at the first sign of dropping revenue after seeing year over year increases for 15 years but I feel more secure as an employed DPM with paid days off then looking at a desk full of problems that I have to fix to stay in business the next year and a list of questions as to what happens with the next health reform, and when that fails then what is next... Probably single payer but what flavor and what stipulations? Podiatrist are not physicians according to Medicaid, So if the health care system builds on that we are in trouble. If it builds off of Medicare, then things would probably go back to the way they were before meaningful Use/ ACA. Could be great. If I had to guess the new system will be built from the Medicare structure and be expanded to include everyone with private insurance supplementing everyone's 20%. But with MACRA type regulations hopefully with some reform to smooth out that process and make it more efficient and not all or nothing penalties or punishments. But I don't know!!

 

[Cranjis McBasketball]

Respectfully disagree on PAs and NPs. After the ACA people realized there was a huge shortage of primary care, but since then there have been sooo many PA and Np programs opening up. These new PA programs are starting to not require any health care experience. And the NP programs are now turning into "get your BSN then your NP online right away." They are gonna have a huge ober supply if things keep going as they are. I cant remember the number but there was a study saying they figured they needed a certain percentage of growth from the number of mid level graduates and they have exceeded that by a long shot. And thats not to mention that when they do graduate they put a ceiling on their autonomy and income. I was looked into the PA profession for a while and wont ever forget talking to a well respected PA in his 50s who hated it. He said it was amazing in his 30s with good pay and a cool job, but now he was at the same place for 20ish years and couldnt make any more money AND a new, wide eyed 30 year old MD grad who had no experience would instantly become his boss. Now thats more of a personality thing but if you go on physicianassistanforum they all dont like where their schooling is headed either, especially cause NPs seem to be leaving them in the dust with their lobbying powerhouse they have

 

[MicroPod]

Thanks for all the thoughtful responses so far. I think this opens up some new discussion topics that I had not thought of before...

Do you think it would be viable for podiatrists to start hiring NPs or PAs? Is this option allowable by law?

Edit: This has already been discussed before. Sorry!

 

[Rop]

Private practice is changing (going down hill) for virtually all physican specialties due to insurance and reglutations. Another thing true for all physican specialities is that we new generations of docs being cranked out year after year are completely unaware of what the "good ole days" of medicine were like. I'm grateful that hospital jobs are becoming ever more common for podiatrists.

 

[esamoham]

Private practice is changing (going down hill) for virtually all physican specialties due to insurance and reglutations. Another thing true for all physican specialities is that we new generations of docs being cranked out year after year are completely unaware of what the "good ole days" of medicine were like. I'm grateful that hospital jobs are becoming ever more common for podiatrists.

Is that really the case. Hospitals are giving podiatrist opportunities to join increasingly?

 

[dtrack22]

1. Student debt and business startup costs are much higher than 10 years ago and dramatically higher than 20 years ago. Which means you cannot take out the equivalent of a fancy car loan to start up a practice. Its big money to put up while waiting for your practice to "build".

You can't do it for as cheap as you used to. I have 7-8 good friends and colleagues that have done it though and are doing well. Nobody has defaulted on any loans yet. You just have to do more market research than you used to, because as you mention, the stakes are higher with higher student loan burdens and startup costs.

2. Meaningful Use now MACRA regulations require about 30-50 thousand dollars into medical records (software and servers) over the first 5 years (2-10K thereafter)

compliant medical records software is cheaper than ever. $30-50k spread out over 5 years isn't a big deal.

3. ACO organization: This is still a developing story, but basically you will have to join to see Medicare patients

No you don't

In many cases they are keeping ingrown toenails, wounds and heel pain in their offices rather than referring these "simple" things out. This translates into less available work.

No they aren't

6. This is not new, but the recent increase in hospital employed DPMs creates an issue in that: first, they have a huge marketing budget, 2nd they get paid facility fees to recoup money that you would could not tap as a competing business. So weather they debride toenails or give a cortisone shot for heel pain, they are getting about a $150 facility fee that you can't get.

The issue this creates is neither of the two you listed. In fact, the facility fee very well bight the hospitals in the butt if we ever start looking at the cost of delivering healthcare. The problem with hospital DPMs is that hospital networks can keep referrals that used to go out into the community, in house. Again, market research is important if you are joining a pod group or starting up on your own. A hospital can swallow up your referral sources overnight. That should be your concern.

7. ACA plans have converted many or most patients to high deductible (5-10,000 dollar) plans so that many patients have opted to refrain from elective surgeries and live with there bunions , hammertoes, heel pains etc.

I'll see your anecdotal evidence and raise you my own. None of the DPMs are having problems booking cases because of deductibles, they are no less busy that they were this time last year and the year before and the year before.

9. Commercial real estate rents and payments --though leveled off, is still about 30-50% more than 10 years ago.

So is residential real estate. But you can still get office space for $18-20 /sq ft/yr.


Private practice is still very doable and lucrative for most. Collecting around $1 mil and having your overhead run around 50% is not a difficult thing for many podiatrists outside of the hospital systems.

The problem with private practice and the reason to become a hospital employee, is to never have to deal with old podiatrists. They are literally the worst. Hospital jobs are not nearly as abundant as private/group practice type jobs, but you are basically guaranteed to be treated fair (initially at least) by the hospital and you will be lucky to get a fair offer from a podiatrist.

 

[TimmyTurner]

The problem with private practice and the reason to become a hospital employee, is to never have to deal with old podiatrists. They are literally the worst.

What is it exactly about older DPMs that make them difficult to deal with? I've heard rumblings about this before, but the only reason I've heard is their tendency to 'take advantage' of the newly minted DPM as an associate- low ball salary offers, high revenue/volume requirements for profit sharing, and only a small slice of the pie if the numbers are hit. Anything besides that?

 

[dtrack22]

1. Student debt and business startup costs are much higher than 10 years ago and dramatically higher than 20 years ago. Which means you cannot take out the equivalent of a fancy car loan to start up a practice. Its big money to put up while waiting for your practice to "build".

To add to this. You will have to take out a business loan of around $200k to start up your own practice. The following are buy ins or valuations I ran across this year...

Practice A valued itself at 80% of gross collections...so 25% ownership (becoming an equal partner at the time you would have bought in) was going to cost you $600k

Practice B was a solo doc nearing retirement, working half time essentially, grossing $500k. Because he was "voluntarily" working part time and had referrals to support full time work, his attorney and accountant wanted him to get between $550-650k for the practice. That is over 100% of gross collections.

Practice C took your most recent 12 months of collections and averaged it with the other partners. Then you paid 50% of that number to buy in. With what the partners were grossing, you'd be looking at an easy $350k buy in. Then, if you wanted "shares" in the surgical suite they had in one office, it was another $150k or so. So to partner, you are looking at $500k.

Now, I know there are practices that only charge you a share of the assets, or have much more reasonable valuations, but these three examples are still within the norm. Is it really cheaper to join or buy a podiatry group than start your own practice? This is also another excellent argument to be employed by a hospital...you don't have to take out more loans just to work for them. An orthopedic group would laugh at these buy ins and valuations too. They don't do this to their associates and they all have higher income ceilings, they could totally afford to...but they don't.

 

[ExperiencedDPM]

What is it exactly about older DPMs that make them difficult to deal with? I've heard rumblings about this before, but the only reason I've heard is their tendency to 'take advantage' of the newly minted DPM as an associate- low ball salary offers, high revenue/volume requirements for profit sharing, and only a small slice of the pie if the numbers are hit. Anything besides that?

The answer is simple. Most are legends in their own minds and forget these aren't the good old days, when practice values were different and managed care didn't exist.

 

[bunNfxr]

I agree, do not get discouraged or encouraged by anecdotal evidence.
Gross collections of a mil??? Check the PM mgmt. survey and consider the likelihood of grossing one. mil. In my experience and discussions with other colleagues, the PM news survey is probably the best view of the realities of DPM practice. Despite its shortcomings, I believe the numbers average out about accurate.
Yes, when I was an associate and discussed my Pod practice buy in with an Ortho friend of mine, (who made 3x as much as me )had a WTF response. And my arrangements were a bit better than those above. The expectations in podiatry are not conforming to todays financial realities or other specialties. The above opinion was echoed by 2 practice brokers that I have spoken with.
The ACO point above is the intended direction of the legislation. I was in one and I am familiar with the system. It did not adversely affect my practice (that I know of). But I dislike the shift in control of a small piece of my own practice to a hospital managed entity. Take it for what you want, but I see it as the nose of the camel under the tent. MACRA legislation mandates that you need to choose an alternative payment model and report quality measures through your billing now. But you are not penalized until 2019. The ACO is the basic model that most private practices are expected to associate with, but their are other options. This is just for Medicare reimbursement. New legislation could move up the deadlines or change the rules but Tom Price has indicated plans to keep MACRA intact. If you are starting a practice, you should recognize that this is a large variable that cannot be fully understood at this time.

Ultimately, if you are graduating, I wish you well and don't think you are doomed. But it is not sunshine and lollipops and hard work is just the half of it.
I'm not going to refute the point by points above. But on the bright side I'll say you don't need 200K to start a practice. But getting the practice going with the expenses you will incur will make you a slave to a bank loan unless you quickly ramp up patient volume well above the averages reported in PM news. 30-50 K for software that reduces your productivity will matter a lot if you are only grossing 200K your first year(And that is more likely than a mil), or two or more. And if your EMR company goes out of business, you are forced to do it all again(eg. Medinotes!!)

The "sunshine act" indicated that 11721 was the most commonly billed code for almost all podiatrist, not 28296. Understand what surgical/vs office/ vs admin portions of your time will be spent on and work out a plan given realistic parameters.

Frame of reference, I know DPMs seeing 60-80 patients a day, that do not make a mil a year. So if you think you are going to see 100 patients a day 3-5 years after opening your office, think again. The average in the PM news survey was about 18 patients a DAY. Most guys I know are pretty well spent seeing 30 patients a day. It depends upon what you are seeing and doing of course, but I'm talking about fairly typical mixed surgical/office based podiatry practices.

 

[NatCh]

For those of you who do start your own solo or small group practice, Practice Fusion's EHR is free.

 

[bunNfxr]

For those of you who do start your own solo or small group practice, Practice Fusion's EHR is free.

Right, but there is no billing module which can cost you more in the long run than an integrated billing system. It is MUCH easier to track your accounts receivable when your EMR, scheduler, superbill, and Billing software are all one system. To each his own, If you are happy with the billing system you have then don't worry about it. But should you start auditing your biller and find that work is not getting done, it is much harder if you have to rely on reports they generate than when you have full control and access to the whole system. Amazing charts is another good low dough program, but again no billing module.

 

[NatCh]

Agreed, you'll pay one way or another. Even paper charts cost money. Our billing costs under $300/month divided by three providers so it would take many years to pay the same amount as one would buying an EHR system (and honestly, who knows what your work scenario might be in 10 or more years). We've had good success with our setup. When we had our EHR on an office-based server we had to pay for updates and all IT service until the system became so clunky and unusable that we abandoned it. The nice thing about free EHR is that you don't pay for updates or IT, and for someone starting a new practice the capital outlay is small -- you don't need to cough up $30K+ right off the bat. One drawback though is that when the internet goes down so does your EHR since it's cloud-based. But yes, everywhere we turn someone is looking to get our money.

 

[dtrack22]

Check the PM mgmt. survey and consider the likelihood of grossing one. mil.

I was initially offered by a doc who worked 25 hours a week (3 days in clinic, 1 half day of OR, every friday off and one thursday off every month), 20 patients a day, a lot of routine care, around 320 patients per month...his gross collections were right at $500k. Anyone who is seeing 60-80 patients a day and not collecting $1 mil is doing something very wrong. That something may just be practicing in the wrong part of the country. But still, not anyone I would be referencing or taking advice from.

PMnews is another area I wouldn't be leaning on if I'm trying to shape my view of podiatry or podiatry practice. MGMA surveys have shown that 50th percentile podiatrists who do any amount of surgery have incomes of around $240k. That's average. PMnews would lead you to believe thats top 10-25%.

Like natch referred to and I think I mentioned, cloud based EMRs have drastically reduced start-up EMR costs for any doc or practice. There is no initial cost, just your $600 a month payment for meditouch (for example).

I'm just hoping that new grads aren't desperate enough to pay what these guys want from a partnership or purchasing standpoint. Or have enough non podiatry practice job offers. Or are ballsy enough to go out on their own. Everyone in medicine (including attorneys and consultants) understand that charts and goodwill don't have the value they once did...everyone except for older and/or retiring podiatrists. Unfortunately bad job offers and bad valuations will continue until people stop accepting them as an inevitability and find other ways to get paid.

 

[NatCh]

Frame of reference, I know DPMs seeing 60-80 patients a day, that do not make a mil a year. So if you think you are going to see 100 patients a day 3-5 years after opening your office, think again.

Anyone who is seeing 60-80 patients a day...

My head is exploding at the thought of seeing that many patients in a day.

 

[dtrack22]

Yeah I'm not sure how you do it without working on charts until 8pm...or having significantly more staff. Which heads towards a discussion I find a lot more interesting, dealing with overhead in the presence of increasing volume, and the high volume/overstaffed clinic vs the lower volume/lower overhead clinic. That could be its own thread if there were enough folks on here willing and able to talk about those numbers. I sure as heck couldn't contribute much to that other than theoretical application.

 

[NatCh]

Even if I had the staff to handle that kind of daily volume, I'm not sure I'd be able to do quality work. When I was a student I spent a month rotating through a clinic in Phoenix where one attending had a high volume and worked at a furious pace. He literally jogged from room to room and spent no more than five minutes per patient. It was too early in my career to assess whether his patient care was high quality or not though.

 

[JewOnThis]

@dtrack22 I am not directing an attack towards you, but my experience and knowledge are similar to @bunNfxr

Judging from what you have posted, it seems like you have only been practicing for a couple of years or so. I could be completely wrong.

I am not going to comment on everything both of you guys said. But for those residents thinking it's a good idea to start up your own, please think again. I have a similar story to dtrack. My friend has been practicing over 25 years in a major city. He sees about 20-25 patients a day x's 3 day and 1 day in the OR. He grosses an average of 300K a year for the past 5 years. He does a lot of what dtrack mentioned above. His overhead is currently at 60% with 2 full time staff. Lets say he sees 75 pts a day, so his gross would be around 900k, he still wont take home 1 mill a year, lol. Like mentioned above, with that amount of patients you have to increase staff which increases the overhead. This is the typical podiatry practice.

 

[dtrack22]

My friend has been practicing over 25 years in a major city. He sees about 20-25 patients a day x's 3 day and 1 day in the OR. He grosses an average of 300K a year for the past 5 years.

Lets say he sees 75 pts a day, so his gross would be around 900k, he still wont take home 1 mill a year, lol.

before I respond to this...I have to ask what you mean by "gross?" I was talking about gross collections. What the practice brings in before any salaries, utilities, liabilities are paid. With you referring to a "gross" of $900K and then immediately referencing "take home" pay, you seem to be discussing gross income of the physician him or herself. Like money after overhead but before uncle sam.

 

[dtrack22]

He literally jogged from room to room and spent no more than five minutes per patient.

I need to do the jogging part...just for my overall health, not patient care...

 

[Cranjis McBasketball]

So what are the disadvantages to being hospital employed?

 

[JewOnThis]

before I respond to this...I have to ask what you mean by "gross?" I was talking about gross collections. What the practice brings in before any salaries, utilities, liabilities are paid. With you referring to a "gross" of $900K and then immediately referencing "take home" pay, you seem to be discussing gross income of the physician him or herself. Like money after overhead but before uncle sam.

I did state gross meaning before everything is paid off. Also when I stated "take home" I meant net.

 

[JewOnThis]

So what are the disadvantages to being hospital employed?

The biggest disadvantage in private practice is that you are treating the insurance not the patient.
Also, lack of benefits such as affordable health insurance (which is pretty important to those with families).

 

[Cranjis McBasketball]

Sorry i meant "of" being hospital employed

 

[JewOnThis]

Haha, the vice versa of what I wrote above.

Most hospital are on a RVU system, so you are actually treating the patients and not the insurance.
Another thing is you have affordable health care, 401K, possibly pension plan as well.

 

[Cranjis McBasketball]

Haha, the vice versa of what I wrote above.

Most hospital are on a RVU system, so you are actually treating the patients and not the insurance.
Another thing is you have affordable health care, 401K, possibly pension plan as well.

What are the disadvantages of being hospital employed

 

[NatCh]

So what are the disadvantages to being hospital employed?

Here's what would bug me. I haven't worked for a hospital since residency though, so it's all conjecture:

• You have to ask for permission to take time off
• Some $%^#&* in middle management who got a 2.3 GPA in undergrad at the University of Phoenix Someone else makes decisions for you
• You have less control over staffing, for example if there is bad support staff you may be stuck and frustrated for awhile whereas in private practice you don't have to put up with bad employees
• You don't practice how you want but rather how administration wants
• Your employment can be terminated
• You're working your butt off to meet production goals in order to make your cute bonus, then read about the CEO getting an eight-figure bonus on top of his $500K salary.
• You get a new EHR system every few years then have to go through lots of learning and relearning before administration figures out that the system doesn't make anyone happy or do what it promised
  
• You have to sit through hours and hours of mandatory corporate education meetings

It looks like most of my reluctance would have to do with loss of control. If you've never been your own boss you might not know any different but now that I've been there I'd hate to give it up.

Edit: I guess if you're an Associate then a lot of the above still applies.

 

[dtrack22]

I did state gross meaning before everything is paid off. Also when I stated "take home" I meant net.

Ok, well first, of course nobody is suggesting its reasonable for any podiatrist to net 1 million dollars...second...

My friend has been practicing over 25 years in a major city. He sees about 20-25 patients a day x's 3 day and 1 day in the OR. He grosses an average of 300K a year for the past 5 years.

So "gross" meaning gross collections, means your friend would be another example of what not to do. Less $90 per patient per clinic visit is bad.

His overhead is currently at 60% with 2 full time staff.

That is definitely not normal...and I'm not sure what's worse, only collecting $300k per year or only getting to keep 40% of it before taxes.

Most hospital are on a RVU system, so you are actually treating the patients and not the insurance.
Another thing is you have affordable health care, 401K, possibly pension plan as well.

Its still essentially fee for service. And to think there is not an equal pressure to produce in a hospital system (rack up more RVUs), compared to a private practice setting, is rather naive. Hospital employee model benefits typically are great, though you have to remember that any hallway intelligent practice owner has thousands of dollars worth of tax advantages that a hospital employee does not. The corporation (i.e. practice) can pay for your car, your cell phone bill, home internet and a portion of the utilities, season tickets to a local sporting team, "work" related travel, home office supplies and furniture, healthcare, a 401k, a portion of your income can be paid out as a dividend and taxed at 15%, student loans, etc. Basically a whole lot of stuff being paid with pre-tax dollars that would otherwise be coming out of your paycheck after taxes as an employee.


Ankle Breaker and Natch nailed the possible downsides of being a hospital employee, and you could make a similar list for docs practicing outside of the hospital system. The only thing I'd add to those posts is the ability to invest in or utilize ancillary revenue streams. Hopefully the hospital compensation is generous (either in the base salary or on a $/RVU basis) because they factor in downstream revenue.

 

[JewOnThis]

@dtrack22 , I honestly am not sure who I am really talking to. Are you a resident or a practicing podiatrist?

What do you think the average overhead is for a solo podiatry practice?
What CPT codes do you bill for your services? And how much do you really get in return (and sometimes after refunds?)


I think it is great that have posted your input (I am sure it makes the residents or prepods appreciate podiatry more), but the truth is in most podiatry practices.... money is hard to come by. It is not what it was like 8-10 years ago. You will hear this over and over again from private practice owners.

I have worked in different areas from major metros to small cities. I can tell you that there are still a couple of solo podiatry practices around my area (population of 700,000+), but most of them are joining together due to high overheads.
Heck, before I left my "small" city job (population of 200,000), most of the practices were being closed. A lot of those owners later became employees.

Before I sign off, I just want to say one thing. There are people here with real practice experiences such as @bunNfxr , @ExperiencedDPM , and @NatCh . These people should get more credit for contributing to the forum. Please show more respect to those that "paved" the way for you young folks.

 

[bunNfxr]

I will also bring to light that the quest for high gross collections can go awry. Be careful saying that someone is doing something wrong because their collections vs patient volume does not meet your expectations. One of the biggest threats to your well being in practice is over coding. The biggest examples are with Toenail issues, namely billing 11730's on patients without consents and documentation of anesthesia administration. The other is billing 99212 in lieu of 11719 which is generally uncovered or pays a whopping 17 dollars when it is covered vs around $60 for E&M code. But if you get caught you could be looking at paying back an extrapolated sum that will put you into poverty or send you to jail. I know of a few DPMs in this position as well. Over coding E&Ms can get you into trouble too, but that has not been a big target of the OIG in recent years. Another big issue is a 25 modifier on subtalar fusion for you arthroerisis. And similar issues for coblation. These are undefined procedures and essentially are unreimbursible by insurance so most people find "the best fit code", all of which is essentially illegal in the eyes of the OIG. Yes! taking care of patients can be illegal.
I'm not saying that everyone who sees 25 patients a day and grosses 500K is doing these or other incorrect coding applications. But usually something is not right and at the very least , it is those on the high ends of the reimbursement per patient and total reimbursement curves that will get audited. You may pass, but you'll still pay in lost time and worry and aggravation. It is a shame when you have to pay to defend yourself when you have done nothing wrong. But that is the way it is and no proposed healthcare reform has sought to change it. They often spend more in fraud and abuse then they recover (If you look at the final rate of returned recoveries from contested audits).
Also note that about 22% of Meaningful use audits result in return of incentive funds (18 k for the first year less for subsequent years). 25% of Practices are Failing Meaningful Use Audits
But if you are thinking about starting a practice understand that the past administration sought to increase audits 5 fold and no one is proposing a change.

 

[bunNfxr]

People generally bill for a STJ arthrodesis +25 mod. Though most implant companies will not take responsibility for recommending that code. You have to bill at as an unlisted procedure 28899. In order to get paid for this you have to pre cert the procedure and code and even then it will usually get denied. Then you may win on appeal if you wrote down the name of the person that gave you the precert and get in writing that they will pay for the procedure and the implant. The pre cert does not in fact guarantee payment. But, allows the patient to have the procedure. Essentially saying we'll pay the Hospital, but your unlisted code will get called experimental and uncovered, after you have done the procedure and submitted your billing. Some people will do a posterior tendon repair and put the implant in without billing that part of the procedure. I've also heard of some people saying that pes planus is an STJ dislocation and then billing the arthroeresis as a reduction of an STJ dislocation with internal fixation (The implant). May seem plausible, but according to doctors I know paid to review these claims, it is fraud and you are putting your career in jeopardy.

 

[ExperiencedDPM]

I will also bring to light that the quest for high gross collections can go awry. Be careful saying that someone is doing something wrong because their collections vs patient volume does not meet your expectations. One of the biggest threats to your well being in practice is over coding. The biggest examples are with Toenail issues, namely billing 11730's on patients without consents and documentation of anesthesia administration. The other is billing 99212 in lieu of 11719 which is generally uncovered or pays a whopping 17 dollars when it is covered vs around $60 for E&M code. But if you get caught you could be looking at paying back an extrapolated sum that will put you into poverty or send you to jail. I know of a few DPMs in this position as well. Over coding E&Ms can get you into trouble too, but that has not been a big target of the OIG in recent years. Another big issue is a 25 modifier on subtalar fusion for you arthroerisis. And similar issues for coblation. These are undefined procedures and essentially are unreimbursible by insurance so most people find "the best fit code", all of which is essentially illegal in the eyes of the OIG. Yes! taking care of patients can be illegal.
I'm not saying that everyone who sees 25 patients a day and grosses 500K is doing these or other incorrect coding applications. But usually something is not right and at the very least , it is those on the high ends of the reimbursement per patient and total reimbursement curves that will get audited. You may pass, but you'll still pay in lost time and worry and aggravation. It is a shame when you have to pay to defend yourself when you have done nothing wrong. But that is the way it is and no proposed healthcare reform has sought to change it. They often spend more in fraud and abuse then they recover (If you look at the final rate of returned recoveries from contested audits).
Also note that about 22% of Meaningful use audits result in return of incentive funds (18 k for the first year less for subsequent years). 25% of Practices are Failing Meaningful Use Audits
But if you are thinking about starting a practice understand that the past administration sought to increase audits 5 fold and no one is proposing a change.

This post is one of the best I've read in a long time. Over the years I have been a hired consultant for insurance companies, and I have recently spent more time doing this since I really enjoy it.

Please don't listen to reps who tell you how to bill and please be cautious when attending seminars that tell you how to bill differently to make more money.

Your documention needs to support your procedure. You can't document that a wound is 1 mm in depth and then bill a 11043 which is debridement into muscle or fascia.

Every arthroreisis I see billed is either billed as a subtalar arthrorDESIS (without a modifier) or reduction of a talo tarsal dislocation. In my opinion billing either one of those is pure fraud. When using one of these devices you are performing NO parts of a subtalar arthrodesis. You are in the sinus tarsi and not in the STJ. Even billing as a reduced service is fraud. A talo tarsal dislocation is a traumatic event and not resolved with a device popped into the sinus tarsi. It may be a "hypermobile" joint or may be mildly subluxed, but it is NOT dislocated. Billing it as a reduction of a dislocation is fraud.

I also see a lot of docs billing a 11305,11306 and 11307 when trimming an IPK or keratotic lesion. The code is a shave of an epidermal lesion for biopsy and requires anesthesia. It's not for palliative care every few weeks.

The list goes on and on. And when I review these cases I often wonder how many times these doc HAVE gotten paid for a 10 procedure performing an arthroreisis and billing for a STJ arthrodesis.

I wonder how many times a doc has billed a 11305 and got paid for doing nothing more than trimming a lesion.

You can make a LOT of money being a fraud. Just be prepared to eventually go to jail. Read up on Dr. Young of Detroit who was making ridiculous money and got nabbed for 13.9 million. Read up on Dr. Monaco of Pennsylvania who was living high on the hog and got nabbed for over 5 million in fraud.

I've been in the business for quite a while. I know what it takes to make money. Any DPM who brings in one million by himself/herself is either a thief or one amazing individual.

Billing a million isn't that difficult. With today's reimbursement, collecting one million for one doctor is not an easy feat and would raise my eyebrows.

I know the math and it sounds easy. See 40 patients a day at 100 bucks a pop and work 5 days a week for 50 weeks and you've got a million.

When you get into practice and realize not everyone is seeing 200 pts a week and that reimbursements are low, you'll understand.

Be honest, do the right thing for your patient and you will make a nice income. Be a pig and a thief and you will make huge money, and then will get cocky until you lose everything and go to jail.

The OIG knows who to look for and what to look for. They take their time and an investigation can take years, because they want an ironclad case. And once they've got you......you're done.

 

[heybrother]

Medicare Unmasked: Behind the Numbers

The above link should pull Monaco's Medicare billing.

 

[ExperiencedDPM]

Medicare Unmasked: Behind the Numbers

Scroll down and look at this guy's numbers.

 

[Weirdy]

For the uninitiated:

2012- $917,821
2013 - $983,116
2014 - $876,658

......yowsers.

 

[Creflo]

I fully appreciate that there are and have been crooks. But what about the fact that we don't get medicare billing and coding training in school (not much), some residencies don't teach it well either. Then when you hit the real world and want to do it honest, you can't get anyone on the phone at the MAC. Then you look for an LCD from your MAC for the most commonly billed podiatry procedures and there isn't one. Then you are playing guessing games to determine which region's LCD they will follow when they audit your charts. I've spent hours studying and paid hundreds of dollars on consultants and seminars to try to figure out how to bill and code honestly as I'll soon be working in civilian practice full time. I've done this not to get one over on medicare, but to try to stay out of trouble. Different consultants tell you different things, because often it isn't black and white. One consultant tells you if you diagnose PVD as qualifying nail care systemic condition that you need to notify the PCP, then another consultant says not necessary. One person says you need a doctor's note for seeing nursing home patients for at risk nail care, then another person says no you just need request from patient or family member. One expert says chart antifungal prescriptions in order to get paid for at risk toenail care, then others say not necessary. The list goes on... and this is just for basic chip and clip stuff. Then you take the fact that most providers will eventually get audited, and when you do, it may be a high school educated person looking for certain buzzwords in the chart. So some experts tell you to use words from medicare guidelines verbatim, and bold print the buzzwords, so the auditor will understand the language and you will hopefully pass the audit. Because if you don't, and they audit 40 visits out of 2,000 visits, and you fail 20 of the 40, you get a bill to repay 50% of all the money you collected for the 2,000 visits. So instead of just charting good medicine, you are sort of playing a game of charting what you think will get you past the non-physician auditor.

I may be wrong in my impressions, and I'm somewhat of a newbie to medicare, but this is the gist of how it works according to many that I've talked to. Please tell me if I'm wrong. I wish we would discuss billing and coding more on SDN. That and residency reviews are the most valuable things on here imo. I agree, the crooks should be dealth with, but it's costing all of us too much.

 

[NatCh]

It's all way too complex. I picture a government employee sitting at a desk having to come up with a new rule per day in order to justify his or her employment. "Let's see, what arbitrary rule can I come up with today? Gotta stay on this gravy train."