In office procedure profitablity

SDN Members don't see this ad. (About Ads)

In general what are the most profitable in office procedures?

I think that ingrown nail procedures (not slant backs) are pretty profitable in the office setting.

how about MIS (minimal incision surgery) procedures?? seems like if you could do lots of hammer toes and heal spurs in office you could pull in some decent profits. My grandpa used to fix corns that way as well, shorten the metatarsal just a hair so it didn't protrude further than the rest, with a burr in office.

Originally Posted by RockFoot

how about MIS (minimal incision surgery) procedures?? seems like if you could do lots of hammer toes and heal spurs in office you could pull in some decent profits. My grandpa used to fix corns that way as well, shorten the metatarsal just a hair so it didn't protrude further than the rest, with a burr in office.

With all due respect to your grandfather, although performing "MIS" in your office can certainly be a money maker, I can't think of one other reason to perform the procedures you mentioned.

The majority (not all) of the doctors who I have known over my many years of practice who performed MIS, were doctors who did not have formal surgical training or did not have hospital privileges.

About the only time I believe MIS is acceptable is when a patient has a small bony prominence/exostosis that needs to be smoothed down.

The problem with MIS surgery is that you are placing a high speed burr (usually a Shannon 44) into a small hole BLINDLY and you have no idea what tissue you are destroying. Many people have anomalous anatomical findins, and sticking a burr in a hole blindly can "wrap" a nerve, blood vessel, tendon, etc, around the burr.

One of the first things I was ever taught in surgery is to never put your blade where you can't see it, and in MIS surgery that's exactly what you're doing.

Please do not confuse MIS with laparoscopic or endoscopic surgery. In those procedures you are visualizing the surgery on a screen, not working blind.

And that's just the beginning of why I believe this type of surgery is dangerous. The ONLY good thing about this type of surgery is that I've made a lot of money correcting and fixing the major problems it has caused.

Ive heard of these issues but had also read that with modern technology (scopes) MIS could see a rebirth of sorts.

Sent from my SPH-D600 using SDN Mobile

Originally Posted by RockFoot

Ive heard of these issues but had also read that with modern technology (scopes) MIS could see a rebirth of sorts.

Sent from my SPH-D600 using SDN Mobile

I haven't actually looked it up but I would imagine that this equipment would carry a pretty hefty price tag. I don't think it would be financially prudent. Maybe one of the attendings could chime in on this.

- Ingrown nail procedures (avulsion, matricectomy)
- Plantar warts (destruction of benign lesion)
- Injections (steroid, ETOH sclerosing)

FYI:
http://www.podiatrytoday.com/emergin...on-osteotomies

If I did do MIS, I don't think I'd do it in the office.

thats a great article, thanks!

Sent from my SPH-D600 using SDN Mobile

Originally Posted by PADPM

Many people have anomalous anatomical findins, and sticking a burr in a hole blindly can "wrap" a nerve, blood vessel, tendon, etc, around the burr.

Sounds delightful......

Originally Posted by RockFoot

Ive heard of these issues but had also read that with modern technology (scopes) MIS could see a rebirth of sorts.

Sent from my SPH-D600 using SDN Mobile

That's why I recommended that you don't confuse MIS with arthroscopic or endoscopic surgery. With endoscopic and arthroscopic surgery, although there is a small incision, the structures are still being visualized.

With the "old" MIS that was performed by DPM's,, it was blind surgery.

Big surgeons make big incisions

yeah, I believe the blind approach was what my grandfather was doing in the 70's and 80's but during the 90's he began using a scope and heartily recommends that approach. (he retired in 2000).

And yes, he did not have a surgical residency and MIS was the way for him to get in on the surgical side of things.

Originally Posted by UVAallday

In general what are the most profitable in office procedures?

Today, every single procedure and surgery done in your office/surgical center will be more profitable than going to the nearby hospital.

Originally Posted by newankle

Big surgeons make big incisions

Ha, haven't heard that one in a long time.

Originally Posted by JonScholl

Today, every single procedure and surgery done in your office/surgical center will be more profitable than going to the nearby hospital.

It depends what materials are needed for the specific procedure... you don't get paid for the suture, bandages, drapes, chemicals, etc etc.

Originally Posted by Feli

It depends what materials are needed for the specific procedure... you don't get paid for the suture, bandages, drapes, chemicals, etc etc.

Lets say that you have a surgical center in your office that is equipped to do almost any podiatric surgical procedure. Give me an example where doing a procedure in the hospital instead would be more profitable.

Lets say that you have a surgical center in your office that is equipped to do almost any podiatric surgical procedure. Give me an example where doing a procedure in the hospital instead would be more profitable.

Are you talking about an in office suite or a medical building that has a surgical center that your office is located in? You make it seem like you are referring to a suite in your very own office in which case....

Who is paying for the screw(s) you are using? Plates? Have you bought your own arthroscopic equipment to do scopes with? Casting materials?

Any of those will eat into or completely erode any profit you made on the procedure. Of course you can use k-wires to save money but then I can rattle off a ton of procedures that you wouldn't be able to do.

Originally Posted by JonScholl

Lets say that you have a surgical center in your office that is equipped to do almost any podiatric surgical procedure. Give me an example where doing a procedure in the hospital instead would be more profitable.

Any procedure with an expensive implant might cost you more than what you'd make. Make $1000 for the procedure, spend $3000 for the implant.

BTW, when I read "in office" procedure it means to me something you'd do in one of the treatment rooms rather than in a surgical center attached to your office. i.e., a matricectomy, not a Lapidus.

somewhat o/t but for the less informed, how does one make money on a procedure that pays 1k and needs 3k of implants?

Sent from my SPH-D600 using SDN Mobile

Originally Posted by RockFoot

somewhat o/t but for the less informed, how does one make money on a procedure that pays 1k and needs 3k of implants?

Sent from my SPH-D600 using SDN Mobile

You do the procedure in a hospital or surgery center and let them pay for the implants. Hospitals can bill insurance for implants. Surgery centers absorb the cost.

I see, why cant a surgery center?

Sent from my SPH-D600 using SDN Mobile

Originally Posted by RockFoot

I see, why cant a surgery center?

Sent from my SPH-D600 using SDN Mobile

Them's the rules.

Both the hospital and the surgery center bill an O.R. fee though. As long as your case doesn't cost more to do than the O.R. fee, the surgery center can make a profit. If you have a surgery center in your office but it's not an accredited surgery center, you can't bill for that O.R. fee. In that case you absorb all costs.

yea i was more talking about procedures done in office not including surgery centers/suites. Like an ingrown toenail was a good example of an in office procedure.

Think about it this way. The surgeon gets paid surgeon's fee for the procedure billed to the patient (small fee). The hospital or surgery center bills for the facility fee based on the allowable by insurance based on the procedure code complexity. The anesthesiologist group bills their fee for services. The facility also bills for DME dispensed, meds, and ancillaries/materials. For implants the facility buys the implant from the implant company and bills the patient. So in the end for say a bunionectomy the patient may get billed $1000 and insurance allows/pays $500. Also patient gets billed maybe $6000-$7000 by the facility for these other services. At one of my hospitals they refuse to allow me and a fellow orthopod from another group do TARs because the cost of the implant itself is cost-prohibitive so they feel they don't make enough or lose money on those cases. So I take those cases to another hospital that wants me to do them because it is a good advertisement for their facility.

this type of information is worth more than gold to me. it gives me a better understanding of how the US medical industrial complex works and thats not something I can just google, its not really out there for public consumption, thanks.

Sent from my SPH-D600 using SDN Mobile

Not to hijack this thread, but our office has recently been experiencing a great way to LOSE your profits.

We have recently had a run of deaf patients come to our office demanding that they be provided with an interpreter. In the past, we attempted to make every accommodation possible (we even had a staff member who "signed") and handed out pads of paper to help with communication. If that wasn't helpful to the patient, we would get an interpreter to allow the patient to feel more comfortable.

Now we have had a large amount of deaf patients who won't try that approach and insist on an interpreter. That interpreter cost US (not the patient) $150 an hour, with a one hour minimum. So if we see a patient with a Medicaid type insurance, where we receive about 35 bucks or less for an office visit, we are in the red for $115. If that patient needs to be seen weekly, etc., WE have to cover that cost.

I am very sensitive to the needs of these patients, but feel that we should have the ability to at least have the patient attempt to communicate with pad and paper. If that is not helpful for the patient, there should be government programs to pay for the interpreter. After all, we are not in business to lose money every visit.

I feel it's ironic that these programs will pay for custom orthoses (if the patient goes to an approved facility) for just about any minor or major foot pathology, but they won't pay for an interpreter.

This requirement to provide an interpreter is part of the American Disabilities Act. I'm not saying these patients don't require/need/deserve an interpreter, I just think it's absurd that the doctor has to cover the cost.

Originally Posted by PADPM

This requirement to provide an interpreter is part of the American Civil Disabilities Act. I'm not saying these patients don't require/need/deserve an interpreter, I just think it's absurd that the doctor has to cover the cost.

I'll say it: These patients don't deserve an interpreter. I don't understand how you have to use your personal property to pay for their mishap...

Can you refuse treatment to this patient? Or is that illegal too?

Originally Posted by MaxillofacialMN

I'll say it: These patients don't deserve an interpreter. I don't understand how you have to use your personal property to pay for their mishap...

Can you refuse treatment to this patient? Or is that illegal too?

I believe that would be illegal.

See ADA Title III: Public Accommodations
http://www.ada.gov/cguide.htm

http://www.olrs.ohio.gov/right-to-sign-interpret

http://www.olrs.ohio.gov/sites/olrs....ter-rights.pdf

Originally Posted by NatCh

I believe that would be illegal.

See ADA Title III: Public Accommodations
http://www.ada.gov/cguide.htm

http://www.olrs.ohio.gov/right-to-sign-interpret

http://www.olrs.ohio.gov/sites/olrs....ter-rights.pdf

Ah yes, the Nanny-state strikes again... Hmm i'm sorry PADPM, this really sucks.

Originally Posted by NatCh

I believe that would be illegal.

See ADA Title III: Public Accommodations
http://www.ada.gov/cguide.htm

http://www.olrs.ohio.gov/right-to-sign-interpret

http://www.olrs.ohio.gov/sites/olrs....ter-rights.pdf

I thought yesterday this stuff only applied to public places (including non-public, public places, like movie theatres and mega malls) but this act seems to apply to commercial space as well... Bummer..

Just learn sign yourself

Carefully tread here... We have a large deaf patient population and had a lawsuit filed against the practice many years ago. If you do not make reasonable accommodations they will make you bend over backwards and do all sorts of additional things that you will think are way above and beyond what is considered reasonable and you will have to pay for it. We offer the patient the option of communicating via pen and pad or having an interpreter present and yes we have to pay for it and our deaf patient volume is high. I personally see 1 to 2 per week every week on average. The interpreter cost is high. I recommended to the practice that we start up an independent company that provides this service so we can make some money off of it. The interpreters generally work part time for these groups. You cannot avoid it. There are videoconferencing services that provide the service as well but then there's a cost for equipment involved. Some patients can lip read well and some use their blackberries to type. We also have an international languages phone service to make accommodations for non English speaking patients and yes that costs a lot as well.

Can you just refer them to someone else? Maybe a practice where they have people who sign?

Originally Posted by SuperFeisty

Can you just refer them to someone else? Maybe a practice where they have people who sign?

No, that's discrimination. It would be no different than referring out all your Asian patients, all your Muslim patients, all your Jewish patients, all your Hispanic patients, etc., etc. In the eyes of the law, it's discrimination. If you're in the game (practice) you have to play by the rules, and not make them up as they suit you. Basically, it's the price of doing business.

Originally Posted by PADPM

No, that's discrimination. It would be no different than referring out all your Asian patients, all your Muslim patients, all your Jewish patients, all your Hispanic patients, etc., etc. In the eyes of the law, it's discrimination. If you're in the game (practice) you have to play by the rules, and not make them up as they suit you. Basically, it's the price of doing business.

I understand.

Great thread. My question is, if a deaf patient comes to your office - are you given a reasonable time frame to accommodate them, as in - you will see them once you find an interpreter? Legally, how long do you as a practice have to set this up? Or is it a must you call an interpreter the day they came to see you?

Can a practice hire someone who isn't an official sign language interpreter to perform signing?

Originally Posted by malleolusman

Great thread. My question is, if a deaf patient comes to your office - are you given a reasonable time frame to accommodate them, as in - you will see them once you find an interpreter? Legally, how long do you as a practice have to set this up? Or is it a must you call an interpreter the day they came to see you?

Can a practice hire someone who isn't an official sign language interpreter to perform signing?

I'm not an attorney, so my answer is simply based on my experiences, and not my knowledge of the actual laws.

We have had different scenarios. We've had deaf patients enter the office willing to simply use a pad and pen, and read lips during the visit. Some have requested interpreters on follow up visits and some new patients call ahead (or a service calls for them) and requests an interpreter. YOU have the option of providing an interpreter or hiring the one the patient recommends, but the patient can not insist on his/her interpreter. If you have to pay his/her interpreter X amount of dollars, and you can find an interpreter that will do the job for 1/2 X, you choose who you want, as long as the job gets done.

We actually had a staff member who "signed", since both her parents are deaf. When the deaf patient came to the office, the patient had known our employee since she was a child. The visit went very smoothly, but the patient requested a DIFFERENT interpreter during follow up visits, since she didn't want our employee to know her medical problems, etc. However, our employee did not look over her records, she simply interpreted for the patient who had heel pain (it wasn't exactly like she had a rare venereal disease!). Our staff signs privacy agreements, and as a result we did NOT have to comply and let her bring in her own interpreter. We provided an interpreter who signed a privacy agreement and that's who we insisted on using, or the patient was given the option of finding another provider.

So, you are not expected to have an interpreter on hand. When receive a call requesting an interpreter, you then have to make the appropriate arrangements for the patient's visit.

Originally Posted by PADPM

I'm not an attorney, so my answer is simply based on my experiences, and not my knowledge of the actual laws.

We have had different scenarios. We've had deaf patients enter the office willing to simply use a pad and pen, and read lips during the visit. Some have requested interpreters on follow up visits and some new patients call ahead (or a service calls for them) and requests an interpreter. YOU have the option of providing an interpreter or hiring the one the patient recommends, but the patient can not insist on his/her interpreter. If you have to pay his/her interpreter X amount of dollars, and you can find an interpreter that will do the job for 1/2 X, you choose who you want, as long as the job gets done.

We actually had a staff member who "signed", since both her parents are deaf. When the deaf patient came to the office, the patient had known our employee since she was a child. The visit went very smoothly, but the patient requested a DIFFERENT interpreter during follow up visits, since she didn't want our employee to know her medical problems, etc. However, our employee did not look over her records, she simply interpreted for the patient who had heel pain (it wasn't exactly like she had a rare venereal disease!). Our staff signs privacy agreements, and as a result we did NOT have to comply and let her bring in her own interpreter. We provided an interpreter who signed a privacy agreement and that's who we insisted on using, or the patient was given the option of finding another provider.

So, you are not expected to have an interpreter on hand. When receive a call requesting an interpreter, you then have to make the appropriate arrangements for the patient's visit.

Great insights. Thanks.

FYI this morning at the surgery center I did 3 cases - 2 ankle ORIFs and a LisFranc's ORIF. I looked at the LisFranc's billing because the ore-auth was in the chart and total bills out to near $13K. Insurance expected to pay around $5K.