Advice for joining a practice

[FALL06]

---

Members don't see this ad.

Hey all,

I was given an opportunity to join a primary care practice but need a little help understanding the logistics of it all.

My understanding is the following:

1. I will be operating under the umbrella of the Primary Care physician's practice (involves several FPs), using their billing system and their facility.

- Will I be able to see patients under their Tax ID number?

2. I was told operating under their practice would make it much easier to get on the insurance plans the practice already has a relationship with.

-Is this true? Also, I should mention the practice is not a multispecialty clinic, YET.

I am still a resident, and this group is a trusted individual, so no foul play is suspected.

Any comments from someone who's knowledgeable in the subject matter would be greatly appreciated.

Thanks!!

 

[hematosis]

Make sure you have a lawyer read all the fine prints. Just curious but around what salary range are they offering you?

 

[PADPM]

I don't know the details of the arrangement , but as per the prior post, use an experienced attorney and CPA.

You must do your homework. Some insurance companies, specifically HMOs do not allow a referral to a specialist within the same walls as the practice. If the specialist is down the hall in another suite it's ok, but not if it's actually within the walls of the practice. This is unique to some insurance carriers.

Additionally, you will be limiting the spectrum of referrals you may receive. Chances are that no other primary care physician (internist, GP, FP, etc.) will refer you patient because that would mean sending a patient into their "competitors" office (since you will be working for/with PCPs in your group). You will have to determine if the docs in your group can realistically generate enough business to keep you busy. Especially when considering you will most likely not receive referrals from other PCPs if employed by other PCPs.

Just my thoughts.

 

[Shannon44]

Hey all,

I was given an opportunity to join a primary care practice but need a little help understanding the logistics of it all.

My understanding is the following:

1. I will be operating under the umbrella of the Primary Care physician's practice (involves several FPs), using their billing system and their facility.

- Will I be able to see patients under their Tax ID number?

2. I was told operating under their practice would make it much easier to get on the insurance plans the practice already has a relationship with.

-Is this true? Also, I should mention the practice is not a multispecialty clinic, YET.

I am still a resident, and this group is a trusted individual, so no foul play is suspected.

Any comments from someone who's knowledgeable in the subject matter would be greatly appreciated.

Thanks!!

One of the residents showed me this post. This is a GOLDEN opportunity to establish a fantastic Podiactric medical and surgical practice with NO orthopedic surgeon or other Podiatrists to compete with. They will also be coming to you straight from the PC doc and you will have instant street cred! Grab it! Do like the other poster stated however, have a pro with experience analyze the contract and don't be timid to negotiate.

Congrat.

 

[tenaciousplus]

deleted

 

[FALL06]

Make sure you have a lawyer read all the fine prints. Just curious but around what salary range are they offering you?

Thanks for the replies everyone.

Perhaps I'm even a little confused.

My understanding is, I'd be working within their practice, under their tax ID, but still have full autonomy. I will not be getting a salary, but rather seeing my own patients and taking home whatever I generate.

Is this scenario unrealistic?

Thanks so much for your help everyone, I really appreciate the feedback.

 

[NatCh]

Thanks for the replies everyone.

Perhaps I'm even a little confused.

My understanding is, I'd be working within their practice, under their tax ID, but still have full autonomy. I will not be getting a salary, but rather seeing my own patients and taking home whatever I generate.

Is this scenario unrealistic?

Thanks so much for your help everyone, I really appreciate the feedback.

I would definitely consult an attorney to make sure that scenario doesn't cause any issues.

If it checks out then it sounds like a great opportunity. How many FPs are there in the group? If the group is big enough you should get adequate referrals even if all of the other FPs in town avoid you.

 

[FALL06]

I would definitely consult an attorney to make sure that scenario doesn't cause any issues.

If it checks out then it sounds like a great opportunity. How many FPs are there in the group? If the group is big enough you should get adequate referrals even if all of the other FPs in town avoid you.

Thanks for the post.

Looks like 4 and myself. Things will be changing over the next year, so not totally sure what the profile of the practice will be at that time.

 

[NatCh]

Thanks for the post.

Looks like 4 and myself. Things will be changing over the next year, so not totally sure what the profile of the practice will be at that time.

4 FP's isn't all that many. 20+ would be better, but 4? How many FPs are in the local community?

 

[PADPM]

Believe me........not receiving referrals from other PCPs is a very real concern, and even greater if the practice only has 4 GPs. No one is going to convince me that 4 GPs are going to generate enough referrals consistently to make a good living, unless they completely over-utilize your services. It appears that you are really taking all the risk. You are not guaranteed a salary, so you are completely dependent on them, and if for some reason it doesn't work at, as tenacious pointed out, you may have a restriction clause which sometimes can be enforced, or at the very least is expensive to litigate. That prevents you from opening across the street. It sounds as if this group wants to cash in on your skills, almost like an experiment to see if it works. IF you were getting a guaranteed income it would be an entire different story.

I personally believe that if you have the opportunity to join a multi disciplinary group, that allows for much greater opportunity.

I don't want to burst your balloon, but I've witnessed the scenario you proposed. And I have very strong doubts that a group of 4 can realistically generate that much foot and ankle pathology.

Please consider my thoughts, they are based on significant experience.

 

[Feli]

I'm suprised nobody mentioned it yet, but the main thing I'd be wary of is that (unless you went to a residency where you get a lot of office exp) you have almost no idea how to bill podiatry office services as a resident. The PCPs won't really be able to help you with that, their office manager and biller will be used to billing just the PCP's E&M and lab services (few if any DPM type procedures and DME stuff... and probably zero surgical billing exp), and there are no other DPMs to help you out. If you don't catch the billing errors/omissions you are making, nobody will. You will miss out on a lot of $ by making the same mistakes over and over again. I'd strongly strongly consider joining the AAPPM if you are even thinking of going to a group with no other DPMs who can mentor you a bit in the early going.

Also, you will have no other DPMs in your group to do "curbside consults" with. While you can always look that stuff up, it will slow you down greatly (since you'll already be struggling mightily with the billing for awhile). As a resident, you always had orther attendings, other residents, etc of your same specialty nearby and able to help you, but in the PCP clinic, you will be seeing many many more patients with the basic nail, derm, etc podiatry problems as opposed to the bone/joint/wound stuff you tend to see in residency. It sounds dumb, but how often have you really treated a lot of that stuff (orthotics, derm lesions and rashes, nail procedures, peds stuff, etc) since pod school? You've always taken it for granted that the pod-specific diagnostic instruments, tools, bandages, pads, solutions, etc are there for you, but that just won't be the case in a PCP office. What are you going to find in a PCP office for a verruca? To cast orthotics with? Most residencies are very heavy on surg and inpatient care but but pretty thin on regular outpatient clinic podiatry. It takes a lot of planning to be ready for the patient care stuff too (on top of the billing, documentation, marketing and networking, etc etc etc).

With more and more of the DPM grad residents joining multispec, ortho, hospital, etc groups, I guess I went with the "old school" option of just going to a single specialty group. However, I'm only a couple weeks in and can already say that my podiatry biller, office manager, and hiring DPM have been invaluable with helping me along the way with coding, marketing, hospital and insurance paperwork, etc etc. I'm learning what health plans cover which treatments, coding mistakes, and good treatment ideas (from both a pt care and prac mgmt standpoint) that I hadn't seen or even thought of every day. There are definitely some bigtime advantages to being in a single specialty group (or at least having another experienced DPM in your multispec or ortho group). JMO

...Additionally, you will be limiting the spectrum of referrals you may receive. Chances are that no other primary care physician (internist, GP, FP, etc.) will refer you patient because that would mean sending a patient into their "competitors" office (since you will be working for/with PCPs in your group). You will have to determine if the docs in your group can realistically generate enough business to keep you busy. Especially when considering you will most likely not receive referrals from other PCPs if employed by other PCPs....

This is a very good point also^^
Many other FP and IM docs will be wary of your group's PCPs "stealing" patients if they send them to you for F&A stuff. That is something to really think about. As a specialist, the new patients sent to you by PCPs are the lifeblood of your practice.

 

[NatCh]

Feli, are you no longer a Resident? Now in practice? Congrats!

 

[NatCh]

Believe me........not receiving referrals from other PCPs is a very real concern, and even greater if the practice only has 4 GPs. No one is going to convince me that 4 GPs are going to generate enough referrals consistently to make a good living, unless they completely over-utilize your services. It appears that you are really taking all the risk. You are not guaranteed a salary, so you are completely dependent on them, and if for some reason it doesn't work at, as tenacious pointed out, you may have a restriction clause which sometimes can be enforced, or at the very least is expensive to litigate. That prevents you from opening across the street. It sounds as if this group wants to cash in on your skills, almost like an experiment to see if it works. IF you were getting a guaranteed income it would be an entire different story.

I personally believe that if you have the opportunity to join a multi disciplinary group, that allows for much greater opportunity.

I don't want to burst your balloon, but I've witnessed the scenario you proposed. And I have very strong doubts that a group of 4 can realistically generate that much foot and ankle pathology.

Please consider my thoughts, they are based on significant experience.

Agreed, four FPs means only a few patients to you per week at most. That's not much. If it's a small community and you're the only DPM then you would still get referrals from other FPs, but in any larger population it could be suicide,

 

[Feli]

Feli, are you no longer a Resident? Now in practice? Congrats!

Yep, as of a couple weeks ago lol.

Thanks much, man. A lot of the "real world" advice that you and some other attendings have been putting on these msg boards is really making more and more sense every day now. Much appreciated 👍

 

[FALL06]

Believe me........not receiving referrals from other PCPs is a very real concern, and even greater if the practice only has 4 GPs. No one is going to convince me that 4 GPs are going to generate enough referrals consistently to make a good living, unless they completely over-utilize your services. It appears that you are really taking all the risk. You are not guaranteed a salary, so you are completely dependent on them, and if for some reason it doesn't work at, as tenacious pointed out, you may have a restriction clause which sometimes can be enforced, or at the very least is expensive to litigate. That prevents you from opening across the street. It sounds as if this group wants to cash in on your skills, almost like an experiment to see if it works. IF you were getting a guaranteed income it would be an entire different story.

I personally believe that if you have the opportunity to join a multi disciplinary group, that allows for much greater opportunity.

I don't want to burst your balloon, but I've witnessed the scenario you proposed. And I have very strong doubts that a group of 4 can realistically generate that much foot and ankle pathology.

Please consider my thoughts, they are based on significant experience.

I appreciate your concern but this agreement is with a family member. There would be no non-compete and no incentive to profit off my hard work. Just a potential opportunity to expand the family clinic.

We have never done such a project before and are still gathering information.

You have raised some valuable points and I'm very appreciative for calling such issues to my attention. 🙂

 

[FALL06]

I'm suprised nobody mentioned it yet, but the main thing I'd be wary of is that (unless you went to a residency where you get a lot of office exp) you have almost no idea how to bill podiatry office services as a resident. The PCPs won't really be able to help you with that, their office manager and biller will be used to billing just the PCP's E&M and lab services (few if any DPM type procedures and DME stuff... and probably zero surgical billing exp), and there are no other DPMs to help you out. If you don't catch the billing errors/omissions you are making, nobody will. You will miss out on a lot of $ by making the same mistakes over and over again. I'd strongly strongly consider joining the AAPPM if you are even thinking of going to a group with no other DPMs who can mentor you a bit in the early going.

Also, you will have no other DPMs in your group to do "curbside consults" with. While you can always look that stuff up, it will slow you down greatly (since you'll already be struggling mightily with the billing for awhile). As a resident, you always had orther attendings, other residents, etc of your same specialty nearby and able to help you, but in the PCP clinic, you will be seeing many many more patients with the basic nail, derm, etc podiatry problems as opposed to the bone/joint/wound stuff you tend to see in residency. It sounds dumb, but how often have you really treated a lot of that stuff (orthotics, derm lesions and rashes, nail procedures, peds stuff, etc) since pod school? You've always taken it for granted that the pod-specific diagnostic instruments, tools, bandages, pads, solutions, etc are there for you, but that just won't be the case in a PCP office. What are you going to find in a PCP office for a verruca? To cast orthotics with? Most residencies are very heavy on surg and inpatient care but but pretty thin on regular outpatient clinic podiatry. It takes a lot of planning to be ready for the patient care stuff too (on top of the billing, documentation, marketing and networking, etc etc etc).

With more and more of the DPM grad residents joining multispec, ortho, hospital, etc groups, I guess I went with the "old school" option of just going to a single specialty group. However, I'm only a couple weeks in and can already say that my podiatry biller, office manager, and hiring DPM have been invaluable with helping me along the way with coding, marketing, hospital and insurance paperwork, etc etc. I'm learning what health plans cover which treatments, coding mistakes, and good treatment ideas (from both a pt care and prac mgmt standpoint) that I hadn't seen or even thought of every day. There are definitely some bigtime advantages to being in a single specialty group (or at least having another experienced DPM in your multispec or ortho group). JMO

This is a very good point also^^
Many other FP and IM docs will be wary of your group's PCPs "stealing" patients if they send them to you for F&A stuff. That is something to really think about. As a specialist, the new patients sent to you by PCPs are the lifeblood of your practice.

Thanks for your post Feli. I am already a member of the AAPPM but have a lot of research to do regarding billing. I don't know how that would work...I'd imagine I'd do my own billing initially? Sounds tough, but I still see potential in the situation.

Thanks to everyone for reading my posts and sharing your knowledge! I have my work cut out for me...

 

[FALL06]

Congratulations. Here are a few things to consider and talk to your lawyer about:

Setting up your own corporation, either an S corp or C corp to which the practice pays you.

Keeping track of your charts, and keeping copies of them-it seems a little obsessive, but bear with me.

Know what they are billing out. That means having a good knowledge of the ICD and CPT codes. You don't want to start off having someone doing your billing without you knowing every cent that's billed in your name. Many people have had some....not so nice situations when they didn't keep track.

Also keep in mind that if, down the road there is an overpayment by, say medicare, will you be responsible to repay the amount that was in error in full, or will they?

There is something called a restrictive covenant. That means that you agree not to open up your own office, if at some point you decide to down the road. Usually it is some geographic radius.

I would not worry about other PCPs sending you patients or the PCP being concerned he might lose a few to someone else.

What I have done personally over the years was open a satellite office in a nearby town. The best place to do this is NOT in another podiatrists office-you are competition to other podiatrists. I opened many satellite offices with ENTs, Plastic Surgeons, Pulmonolgists, and other medical specialties that had state of the art equipment and we worked out mutually agreeable rental contracts.

The most important thing you are offering the public is your personality. You can have all the training available, the best of the best skills, but if you present yourself poorly, or less than the most sophisticated, best dressed, polished eloquent Podiatric Physcian you'll find things slower than you imagined. Polish is crucial. I can not stress this enough. This is what separates the successful Physcisian from the mediocre. Perception is reality, and if you aren't comfortable with your voice, get voice training, teeth perfect, no excuse for less than excellent grooming, a smile and personable bedside manner. In a sense, it IS a popularity contest, and it's called your career.

Once again, know those procedure codes, and keep your eyes on what's going out. Good luck and like the other said, invest the extra cost with good legal advice. Your lawyer will advise you about the best corporate structure in the state you practice.

Good luck.

Great post!! Thanks for all the insight! I'll certainly look into all these points you made.

 

[Shannon44]

I posted earlier in the day and am reading all this great advise. I still think it could be a great idea. If you opened solo like I did years ago it takes a good 3 - 5 years, or at least it used to, to get that solid and consistent following and cash flow going without stressing out every month. 4 docs right off the bat sending you nails, warts, routine care, heel spurs, etc,, that really is the bread and butter of your cash flow until you establish yourself as the guy to go for surgery. But even if you get that surgey practice going quicker have some more established colleagues show you difference in eob's for surgery v. conservative treatments lately, sobering! Again, good luck and don't lock yourself into anything long term right off the bat.

 

[tenaciousplus]

deleted

 

[NatCh]

Yep, as of a couple weeks ago lol.

Thanks much, man. A lot of the "real world" advice that you and some other attendings have been putting on these msg boards is really making more and more sense every day now. Much appreciated 👍

I think I stopped trying to give out any (marginally) useful real world advice a few years ago, so I'll redirect any credit towards the other Attendings who've taken the time to post. I stick around mostly to provide some (marginally) comic relief I think.

Anyway, it's exciting you're in practice now. May you do great things.

P.S., Don't forget to change your status in the left hand column.

 

[FALL06]

Hey all,

Thanks so much for all of your comments. These posts have helped me direct my search and make the most informed decisions!

One last question.

If the group I potentially join is on a number of insurance plans, would I be incorporated into those plans? Would it just make the process easier....or not at all? Would it make getting on Medicaid/Medicare easier....or would I be viewed like any other provider that opened up cold?

Thanks