118footdoc
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Hey everyone,
I’m hoping to get some perspective from people who’ve been in private practice or gone through associate-to-partner transitions.
I’m about 2.5 years into a three-year associate contract at a small private practice with two senior podiatrists/owners — one male (surgical, 20 years in practice) and one female (clinical/non-surgical, 25+ years in practice). I’m coming up on contract renewal/negotiation and trying to think through some things before that.
First off, I really love this practice! The staff is great, hospital affiliations are solid, my local community is incredible, cost of living is good, and I absolutely love my patients. We do see patients in underserved areas once or twice a month, which I really enjoy. Both of the senior doctors are well respected in the community, and have both been super supportive. They cover my medical malpractice, professional dues to APMA and our local state association, ABFAS fees, conferences, etc. My salary is solid for the area, and I love that there’s room to grow, so I definitely want to stay...however, some operational issues need to be improved, and that's where I need some help.
1. Billing and collections stuff
Even though I’m on salary right now, I’ve started to notice some billing and collections issues that could become a real problem when I would switch to a production/commission model like the owners. We have a single remote biller, and I’ve started noticing multiple patients with very large outstanding balances.
For example, I had an uninsured patient I first saw on hospital call back in March of 2024. As part of call coverage, denying care obviously is not an option. He's a diabetic with neuropathy and infection, needing surgery, etc. After discharge, he chose to follow up with me in the office as he did obtain insurance about 2 to 3 weeks later, but now he has a balance over $6,000. I don't even know how it got that high to begin with...but anyways, I get that self-pay patients can’t always pay their balance in full, but there’s no structured way to track good-faith payments or enforce payment plans, at least from what I have been seeing. Furthermore, that patient after speaking to our biller over the phone, agreed to monthly payments, signed a document in the office with our receptionist stating he would pay $450 on the 12th of every month, provided a card, but never paid because his card kept declining...yet continued to be seen by me, and I didn't know any of this. Because of this, I recently spoke with our biller and asked that my patients receive monthly statements on the 15th, starting in January, with a defined grace period of three months, and eventual collections if there’s no good-faith payment.
Also, some surgeries I’ve done months ago weren’t billed properly, had insurance denials, or even required pre-authorization, yet somehow I was still able to do the surgery at the surgery center. Like…how was that approved if pre-auth wasn’t in place? And now, I’m...or rather the office...is not getting paid a cent for the work I did.
I’m noticing this because it affects future income and practice flow, not my current salary. I know these aren’t technically my responsibilities as the biller or owners should be monitoring this, but it’s concerning to see these gaps early on. Ideally, I would think that the billing person should be reviewing the schedule weekly, checking insurance changes, expired policies, or patients with self-pay balances, and flagging anything high before patients even come in, that way we're proactive instead of being blindsided later on.
Lastly, I just want to say that I love both of my senior doctors. They are honestly amazing...super nice, very skilled, and genuinely want to help people. They're both "charity" kind of doctors in that they'll often provide care regardless of a patient's ability to pay. Sometimes they'll look at a situation and be like "okay, forget about the cost, let's just make sure they get the care they need," which I love. But at the same time, that can create financial challenges. Stuff is not cheap, and it's critical to have solid billing and collections policies in place to keep the practice financially sustainable.
Curious to hear from others:
2. No-show fees
Both the senior doctors don't enforce no-show fees. Recently, I have started to notice these no-shows despite confirmed appointments, especially once my schedule became fuller. It has now become clear just how disruptive this is, especially when those slots could’ve gone to other patients. So about six months in, I asked the front desk and biller to enforce a no-show fee for my schedule. It has helped, but now there’s an inconsistency within the practice, which I feel like could be awkward for both the staff and patients.
Curious to hear from others:
3. HMO/referral issues
This seems like a basic systems issue that should’ve been corrected months into me joining the practice.
This mostly comes up with surgical patients between me and the senior surgical doctor, not so much the non-surgical one. Early on, referrals for those HMO patients were frequently written to him, but given the option to see either of us if it sounded surgical. If they chose me, they were then scheduled under me without correcting the referral. Initially, this made sense while I was still credentialing with insurances. However, now that I’ve been fully credentialed for quite some time, this has still been happening...and we’re not getting paid for those visits. The referral needs to have my name on it for insurance to pay. Otherwise, the visit isn’t reimbursed, and we know referrals aren’t backdated, so the loss is permanent.
It’s frustrating because this is something that could be addressed upfront with proper office workflow and insurance checks.
Curious to hear from others:
4. Board certification and hospital privileges
This is the part I’m least sure how to interpret.
The surgical doctor graduated residency in the early 2000s, has trained many years ago, but is not ABFAS or ABPM certified. From what I know, he did pass the ABFAS written exams but failed case submission twice due to missing documentation...unfortunate, but it happens. At that point, he went and obtained a different certification, ABLES (American Board of Lower Extremity Surgery). I know this specific certification is under the umbrella of the American Board of Multiple Specialties in Podiatry. Now, that certification has folded, and the hospitals we work with (part of a large, citywide hospital system with multiple locations and divisions) have notified him that he must obtain a valid certification to maintain privileges. He recently took some random board exam in October and did pass, but the dates didn’t line up with ABFAS or ABPM testing timelines, so it’s unclear how the hospitals will treat this in terms of ongoing privileges.
From my residency experience, we were constantly reminded that the only truly accredited/recognized boards are ABFAS and ABPM, with ABFAS being the prestigious of the two. These were stressed repeatedly over the full three years of residency, and that anything else might not be accepted for hospital privileges or credentialing. And from what I know about current ABPM/ABFAS rules, you get 8 years after residency to obtain ABPM and two chances to pass ABFAS, and if you fail both chances for ABFAS, there’s no third chance. So I don’t know exactly how this applies to someone who graduated in the early 2000s, but it raises questions about whether he could be grandfathered in or if the hospital system will require proper ABPM/ABFAS certification.
This matters because if privileges aren’t renewed, all surgical cases would default to me, which impacts my workload and could give me leverage in future negotiations, but also raises concerns about patient care, legal exposure, and proper credentialing. Meanwhile, I’m board-qualified with ABFAS in both foot and RRA, and plan on taking ABPM this upcoming October in 2026...because why not?
Curious to hear from others:
5. EMR and workflow
Last but not least...the senior doctors switched from paper charts to our current EMR about 10 years ago. I’ve looked at some older charts when seeing patients who had been followed for years. They were often only 1 to 2 pages: you’d circle if they had palpable or nonpalpable pedal pulses, write if they had hammer toes of bunions, etc, write the diagnosis (“hammer toe” or “bunion”), and note the plan (“new shoes,” “x-rays,” etc.). It was straightforward and to the point. Now obviously, that level of documentation isn’t acceptable today. Medicine now requires much more detailed documentation, not just for patient care continuity, but also for legal and insurance compliance. “If it isn’t documented, it didn’t happen” is the rule.
We currently use an extremely outdated EMR...not Epic, Athena, eClinicalWorks, ModMed, NextGen...or anything commonly used today. We use Praxis, and it’s something I’d never encountered until joining this practice. The system is clunky, not mobile-friendly, and inefficient...and definitely not designed for podiatry. You do not have one single, global “Plan” section. Instead, the plan is built under each individual assessment/diagnosis, so your workflow and templates are entirely dependent on how you structure each assessment. And as more diagnoses are added, parts of previously built templates can disappear or get overridden.
And our IT guy has even said to me that he really only sees this EMR used in primary care or cardiology. And this makes sense, because those patients often have multiple distinct and unrelated diagnoses, so each of those conditions have their own assessment and medication-based plan, so a system that requires a separate plan under each diagnosis makes sense. In podiatry, however, we know that many conditions are interrelated, and treatment plans frequently overlap: supportive shoes, orthotics, stretching, injections, and eventual surgical discussion. Being required to create a separate, repetitive plan under each individual diagnosis significantly slows documentation and adds redundancy.
We also don’t use iPads or laptops as everything is desktop-based. Both senior doctors have dedicated scribes who sit at the desktop and listen to patient encounters via headset/walkie-talkie style devices. I currently don’t have a scribe (which I understand given my current volume), but I’m trying to think ahead to what this workflow looks like as my schedule continues to fill. For me, coming out of residency, I’m used to real-time documentation dictation and mobile devices. Some of the most efficient clinics I rotated through (especially ortho) used iPads or laptops in-room, allowing providers or MAs to document, place orders, review imaging, and discuss plans with patients in real time. So my concern is that as my volume increases, this outdated system will become a major bottleneck...not just for me, but for staff workflow, patient education, and overall clinic efficiency. I’m not trying to see 60 patients a day, but I do think seeing 30 to 40 efficiently requires a more modern EMR.
Curious to hear from others:
6. Context and acknowledgment
All in all, I'm mostly struggling with how to bring all of this up to my senior doctors without coming across as rude, condescending, or like I'm trying to tell them how to run their practice. I really love the practice, the staff, the hospitals, and my patients (more than anything), and I want to stay long-term, so it's not about ego...it's merely about making sure the practice runs smoothly and stays financially healthy. And yes, I get that some of these issues could have been flagged when I signed my contract, but my initial focus was:
Curious to hear from others, and would love some advice:
I’m hoping to get some perspective from people who’ve been in private practice or gone through associate-to-partner transitions.
I’m about 2.5 years into a three-year associate contract at a small private practice with two senior podiatrists/owners — one male (surgical, 20 years in practice) and one female (clinical/non-surgical, 25+ years in practice). I’m coming up on contract renewal/negotiation and trying to think through some things before that.
First off, I really love this practice! The staff is great, hospital affiliations are solid, my local community is incredible, cost of living is good, and I absolutely love my patients. We do see patients in underserved areas once or twice a month, which I really enjoy. Both of the senior doctors are well respected in the community, and have both been super supportive. They cover my medical malpractice, professional dues to APMA and our local state association, ABFAS fees, conferences, etc. My salary is solid for the area, and I love that there’s room to grow, so I definitely want to stay...however, some operational issues need to be improved, and that's where I need some help.
1. Billing and collections stuff
Even though I’m on salary right now, I’ve started to notice some billing and collections issues that could become a real problem when I would switch to a production/commission model like the owners. We have a single remote biller, and I’ve started noticing multiple patients with very large outstanding balances.
For example, I had an uninsured patient I first saw on hospital call back in March of 2024. As part of call coverage, denying care obviously is not an option. He's a diabetic with neuropathy and infection, needing surgery, etc. After discharge, he chose to follow up with me in the office as he did obtain insurance about 2 to 3 weeks later, but now he has a balance over $6,000. I don't even know how it got that high to begin with...but anyways, I get that self-pay patients can’t always pay their balance in full, but there’s no structured way to track good-faith payments or enforce payment plans, at least from what I have been seeing. Furthermore, that patient after speaking to our biller over the phone, agreed to monthly payments, signed a document in the office with our receptionist stating he would pay $450 on the 12th of every month, provided a card, but never paid because his card kept declining...yet continued to be seen by me, and I didn't know any of this. Because of this, I recently spoke with our biller and asked that my patients receive monthly statements on the 15th, starting in January, with a defined grace period of three months, and eventual collections if there’s no good-faith payment.
Also, some surgeries I’ve done months ago weren’t billed properly, had insurance denials, or even required pre-authorization, yet somehow I was still able to do the surgery at the surgery center. Like…how was that approved if pre-auth wasn’t in place? And now, I’m...or rather the office...is not getting paid a cent for the work I did.
I’m noticing this because it affects future income and practice flow, not my current salary. I know these aren’t technically my responsibilities as the biller or owners should be monitoring this, but it’s concerning to see these gaps early on. Ideally, I would think that the billing person should be reviewing the schedule weekly, checking insurance changes, expired policies, or patients with self-pay balances, and flagging anything high before patients even come in, that way we're proactive instead of being blindsided later on.
Lastly, I just want to say that I love both of my senior doctors. They are honestly amazing...super nice, very skilled, and genuinely want to help people. They're both "charity" kind of doctors in that they'll often provide care regardless of a patient's ability to pay. Sometimes they'll look at a situation and be like "okay, forget about the cost, let's just make sure they get the care they need," which I love. But at the same time, that can create financial challenges. Stuff is not cheap, and it's critical to have solid billing and collections policies in place to keep the practice financially sustainable.
Curious to hear from others:
- How do you manage these issues as an associate without overstepping?
- How do you structure your billing workflow to make sure patient balances don't get out of hand?
- How do you handle patients who aren’t showing good-faith payment?
- When does a practice usually escalate to collections? Or is it common to avoid collections entirely?
- How do you balance providing charity care or sliding-scale fees with making sure the practice doesn't lose money or create bottlenecks in revenue?
2. No-show fees
Both the senior doctors don't enforce no-show fees. Recently, I have started to notice these no-shows despite confirmed appointments, especially once my schedule became fuller. It has now become clear just how disruptive this is, especially when those slots could’ve gone to other patients. So about six months in, I asked the front desk and biller to enforce a no-show fee for my schedule. It has helped, but now there’s an inconsistency within the practice, which I feel like could be awkward for both the staff and patients.
Curious to hear from others:
- How have you handled uniform vs. physician-specific no-show policies? And can this inconsistency causes downstream issues?
3. HMO/referral issues
This seems like a basic systems issue that should’ve been corrected months into me joining the practice.
This mostly comes up with surgical patients between me and the senior surgical doctor, not so much the non-surgical one. Early on, referrals for those HMO patients were frequently written to him, but given the option to see either of us if it sounded surgical. If they chose me, they were then scheduled under me without correcting the referral. Initially, this made sense while I was still credentialing with insurances. However, now that I’ve been fully credentialed for quite some time, this has still been happening...and we’re not getting paid for those visits. The referral needs to have my name on it for insurance to pay. Otherwise, the visit isn’t reimbursed, and we know referrals aren’t backdated, so the loss is permanent.
It’s frustrating because this is something that could be addressed upfront with proper office workflow and insurance checks.
Curious to hear from others:
- How do you prevent lost revenue from referral mishaps like this?
- Any tips on implementing a system without annoying patients?
4. Board certification and hospital privileges
This is the part I’m least sure how to interpret.
The surgical doctor graduated residency in the early 2000s, has trained many years ago, but is not ABFAS or ABPM certified. From what I know, he did pass the ABFAS written exams but failed case submission twice due to missing documentation...unfortunate, but it happens. At that point, he went and obtained a different certification, ABLES (American Board of Lower Extremity Surgery). I know this specific certification is under the umbrella of the American Board of Multiple Specialties in Podiatry. Now, that certification has folded, and the hospitals we work with (part of a large, citywide hospital system with multiple locations and divisions) have notified him that he must obtain a valid certification to maintain privileges. He recently took some random board exam in October and did pass, but the dates didn’t line up with ABFAS or ABPM testing timelines, so it’s unclear how the hospitals will treat this in terms of ongoing privileges.
From my residency experience, we were constantly reminded that the only truly accredited/recognized boards are ABFAS and ABPM, with ABFAS being the prestigious of the two. These were stressed repeatedly over the full three years of residency, and that anything else might not be accepted for hospital privileges or credentialing. And from what I know about current ABPM/ABFAS rules, you get 8 years after residency to obtain ABPM and two chances to pass ABFAS, and if you fail both chances for ABFAS, there’s no third chance. So I don’t know exactly how this applies to someone who graduated in the early 2000s, but it raises questions about whether he could be grandfathered in or if the hospital system will require proper ABPM/ABFAS certification.
This matters because if privileges aren’t renewed, all surgical cases would default to me, which impacts my workload and could give me leverage in future negotiations, but also raises concerns about patient care, legal exposure, and proper credentialing. Meanwhile, I’m board-qualified with ABFAS in both foot and RRA, and plan on taking ABPM this upcoming October in 2026...because why not?
Curious to hear from others:
- Will these hospital systems accept this unrecognized (per CPME) certification and grandfather him in without ABPM/ABFAS?
- Have you seen hospitals in large, multi-location city systems ever “grandfathered in” older doctors?
- How would you advise a younger associate to navigate this situation when it could impact surgical workload and negotiations?
5. EMR and workflow
Last but not least...the senior doctors switched from paper charts to our current EMR about 10 years ago. I’ve looked at some older charts when seeing patients who had been followed for years. They were often only 1 to 2 pages: you’d circle if they had palpable or nonpalpable pedal pulses, write if they had hammer toes of bunions, etc, write the diagnosis (“hammer toe” or “bunion”), and note the plan (“new shoes,” “x-rays,” etc.). It was straightforward and to the point. Now obviously, that level of documentation isn’t acceptable today. Medicine now requires much more detailed documentation, not just for patient care continuity, but also for legal and insurance compliance. “If it isn’t documented, it didn’t happen” is the rule.
We currently use an extremely outdated EMR...not Epic, Athena, eClinicalWorks, ModMed, NextGen...or anything commonly used today. We use Praxis, and it’s something I’d never encountered until joining this practice. The system is clunky, not mobile-friendly, and inefficient...and definitely not designed for podiatry. You do not have one single, global “Plan” section. Instead, the plan is built under each individual assessment/diagnosis, so your workflow and templates are entirely dependent on how you structure each assessment. And as more diagnoses are added, parts of previously built templates can disappear or get overridden.
And our IT guy has even said to me that he really only sees this EMR used in primary care or cardiology. And this makes sense, because those patients often have multiple distinct and unrelated diagnoses, so each of those conditions have their own assessment and medication-based plan, so a system that requires a separate plan under each diagnosis makes sense. In podiatry, however, we know that many conditions are interrelated, and treatment plans frequently overlap: supportive shoes, orthotics, stretching, injections, and eventual surgical discussion. Being required to create a separate, repetitive plan under each individual diagnosis significantly slows documentation and adds redundancy.
We also don’t use iPads or laptops as everything is desktop-based. Both senior doctors have dedicated scribes who sit at the desktop and listen to patient encounters via headset/walkie-talkie style devices. I currently don’t have a scribe (which I understand given my current volume), but I’m trying to think ahead to what this workflow looks like as my schedule continues to fill. For me, coming out of residency, I’m used to real-time documentation dictation and mobile devices. Some of the most efficient clinics I rotated through (especially ortho) used iPads or laptops in-room, allowing providers or MAs to document, place orders, review imaging, and discuss plans with patients in real time. So my concern is that as my volume increases, this outdated system will become a major bottleneck...not just for me, but for staff workflow, patient education, and overall clinic efficiency. I’m not trying to see 60 patients a day, but I do think seeing 30 to 40 efficiently requires a more modern EMR.
Curious to hear from others:
- Have you heard of or ever used Praxis? If so, how are you structuring your assessment-based templates to avoid the problem I stated above?
- How hard is it to transition an older practice to a modern EMR? And what EMR do you prefer and why?
- Is anyone currently using AI tools to help with charting efficiency?
6. Context and acknowledgment
All in all, I'm mostly struggling with how to bring all of this up to my senior doctors without coming across as rude, condescending, or like I'm trying to tell them how to run their practice. I really love the practice, the staff, the hospitals, and my patients (more than anything), and I want to stay long-term, so it's not about ego...it's merely about making sure the practice runs smoothly and stays financially healthy. And yes, I get that some of these issues could have been flagged when I signed my contract, but my initial focus was:
- Salary and bonus structure
- Hospital call schedule
- Patient volume expectations
- Future buy-in and partnership opportunities
Curious to hear from others, and would love some advice:
- How do you address operational issues as a younger associate?
- How do you approach contract renewal conversations professionally?
- What are the best ways to collaborate with senior partners to improve practice efficiency?
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