Costs and figures... startup Solo podiatry office

Started by Feli
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Get help with your application

Use all the free resources available to you from SDN: articles, guides, expert advising, forums discussions, and school research.

Browse articles Compare schools My application plan Read Interview Feedback
Practice for interviews Ask an Advisor
Advertisement - Members don't see this ad
heybrother said:
I may eat these words in the future, but at present its unclear to me what they do.

1. I already eat a 3.5% + 30 cent charge from ECWs Healow when the credit card is ran for copays or bills that are paid.
2. Healow will also send out text messages asking the patient to pay their bill and I believe they send paper statements once the patient doesn't respond.
3. So someone is already charging me to run credit cards.
4. I enter my own fee schedules. I enter the billing while I close out the encounter. My receptionist submits the batches and checks them against Trizetto.
5. I'm trying to keep some of these services in house, but I'm likely to need to expand my team to do so.
6. I guess its unclear to me what a biller brings - they want 5%+ of my ACH Medicare that takes no work to collect so that they can claim they are going to pursue my unpaid BCBS charges that aren't going to be paid because once a patient leaves the office with an uncollected balance they won't be back...?

We'll see if I regret this. The best biller argument is "you spend 5% to get 95%" but what the biller really wants is the low hanging fruit. And the funny thing is - I'm OON with Humana, Aetna, and United so I've already dropped the plans that deny claims that need resubmission work. I'm also willing to see fewer people on a Friday to spend an hour going through old claims each week. I don't believe that seeing more patients every single day is actually the best path to more revenue.
Click to expand...
I’m going to pay someone 5.9% and they’ll do the whole RCM (not emr company who outsources to India… they’re a local company and actually are legit) I just don’t have time for it or the staff.

I’d love to cost cut but I feel like the revenue early on is so important and me learning on the fly will sink us.

I feel like if you’re personally going after claims too that can lead to higher burnout as well.
 
CAMBoot said:
I’m going to pay someone 5.9% and they’ll do the whole RCM (not emr company who outsources to India… they’re a local company and actually are legit) I just don’t have time for it or the staff.

I’d love to cost cut but I feel like the revenue early on is so important and me learning on the fly will sink us.

I feel like if you’re personally going after claims too that can lead to higher burnout as well.
Click to expand...
What kind of companies are these that do that
 
Homo sapien said:
What kind of companies are these that do that
Click to expand...
I found these guys locally. Not super local but same state. been in business for a long time. solid online reviews. I looked up their Google reviews and some of the people vouching for them are pretty legit (large ortho group ceo, etc). Talked to them on the phone for 45 mins and was impressed. Now could they be awful? Possibly. But so far I like what I’ve heard.

They kind of shoot it straight too. They aren’t promising to collect 100%. But if I call with a complaint I know they’ll answer and do their best to fix it. These emr/rcm bundles seem like scams.

I went and found a biller before I chose an emr. Because I knew the emr would sell me on everything.
 
Advertisement - Members don't see this ad
CAMBoot said:
I found these guys locally. Not super local but same state. been in business for a long time. solid online reviews. I looked up their Google reviews and some of the people vouching for them are pretty legit (large ortho group ceo, etc). Talked to them on the phone for 45 mins and was impressed. Now could they be awful? Possibly. But so far I like what I’ve heard.

They kind of shoot it straight too. They aren’t promising to collect 100%. But if I call with a complaint I know they’ll answer and do their best to fix it. These emr/rcm bundles seem like scams.

I went and found a biller before I chose an emr. Because I knew the emr would sell me on everything.
Click to expand...
Yep. The primary strength here is better claims submission (claim forms) and better follow up, re-submit, write-off, etc.

The other huge strength is customer service... your office will be very miserable very fast if they have to deal with that stuff. Just give pts a number/email to call for billing questions.

Last, the billing company usually can do cred work if desired. They typically know the area plans and have contacts. They will help train your own staff a bit also.

...Bonus, the billing service doesn't quit, flake out, get sick (in-house biller may do those and leave office up a creek, and EMR billing will raise prices once they have you... just like they do for clinical EMR). The training of billers and staffing for that stuff can be up to the billing company; billing has many nuance skills and is NOT easy work to do well (even for CPC, MBA, etc types). It's probably your most important thing besides immediate support staff (some docs would say billing/collections is #1 thing and even more important).
 
Also reading this thread, very helpful as im thinking i will open up my own shop due to lack of opportunities in my desired area and anywhere within 2 hours of it. I guess im trying to decide if im feeling this financial dread due entirely to my poor decision to go into podiatry, or if the economy and housing prices are just making everything hard for people just starting out. So far, with the exception of going back to school for a MD/DO degree (not possible due to student loan cap), nothing makes financial sense to switch to that I’ve researched.
 
soleproprietor said:
Also reading this thread, very helpful as im thinking i will open up my own shop due to lack of opportunities in my desired area and anywhere within 2 hours of it. I guess im trying to decide if im feeling this financial dread due entirely to my poor decision to go into podiatry, or if the economy and housing prices are just making everything hard for people just starting out. So far, with the exception of going back to school for a MD/DO degree (not possible due to student loan cap), nothing makes financial sense to switch to that I’ve researched.
Click to expand...
You can't leave podiatry after taking out full loans. Sorry. That'd be financial suicide unless you had huge family/spouse help.
No matter what you do, the WCI "live like a resident" is good advice until loans are paid off (and then after, to superfund retirement).
The cheat code is high income partner/spouse that's financially competent. The opposite is SAH who will spend a ton, brings in little/zero. Choices. 🙂
Regardless, you won't find another gig making nearly as much if in residency. Sorry. The time to drop out or pivot would've been years ago.
So, do your best, pay attention in residency and pass all boards to have maximum options and skills.

Your earning power will be ok in podiatry. You can do fine. You will make half - or less - what any MD/DO surgeon makes, but that's still a lot. The podiatry ROI is not good with student loans burden, but you can do much worse. The income surveys are total BS, but realize that you can make it work. Your decent job options will be pretty limited... this happens to every new grad. All are upset when they look for jobs. It is the bucket of poo at the end of the rainbow for most of us. Our DPM job markets are very saturated. Too many podiatrists... and the public demand and overall podiatry market is for keratin, not so much IM nails and fusion plates and Ilizarov that the pod schools try to sell us on. Your basic choices are to going to be:
  • make roughly $200k podiatry PE supergroup (zero owner path, career peaks almost right away),
  • make a bit more in a VA/IHS podiatry job,
  • make a bit less working for a podiatry school,
  • roughly double those if you get a good hospital job, often "pus bus" (pretty hard, even with good residency + ABFAS cert + exp + willing to go anywhere),
  • variable income as PP or MSG or mobile pod or various types of employee (some with partner path, but don't count on it), or
  • do solo PP.
Most grads do the PP employee or supergroup employee jobs. They are the most common ones, easier to find, many locations for those jobs... and many people choose mainly on location. I have done those types. I did IHS and MSG also. Any employed job - podiatry or other - kinda boils down to boss/admins.

...I said it early in the thread, but I did solo PP more for decent income and stability than out of any burning desire to do it entrepreneur route. It's that way for most DPMs: necessity (some exceptions for ppl who had a podiatrist in the family or have a lot of money in the fam to buy in/out a practice early). Like any biz, sky's the limit... basic podiatry and make double what associates do (I'm fine with that, but I have cheat code), or you can expand office, add services, higher volume, hire associates, add offices, etc etc. But yeah, nobody wants to worry if their front desk girl will quit or think about mailing in an audit back or fret about meeting the new PCPs in town asap or ponder why their EMR went up 8% this year... but you simply make a lot more income owner/partner than employed. That is what owning is: more hours, more income. It's what nearly all pods used to do (and dent). A lot MDs do it, and it can be a lot better for money/call. Chiro still don't have any other option (not hosp accepted). You also have stability and no "boss" to answer to.
Sure, we have some hosptial podiatry jobs now. But they don't hire you to lose money; even most of the hospital DPMs aren't living where they want (they went there for a job), and they have call/admin headaches. DPM grads from Inova and Grant and PSL top flight residencies and fellowships don't plan for rural hospitals or Oklahoma or Wyoming to get tiny ortho group or hospital jobs, but podiatry's limited... and that's what they often get. You can try the job market - and you should, but it's good to have solo PP as a potential option (typically after a few years of saving up and getting exp employed). GL
 
Last edited:
Renegotiated a contract today to actually be slightly better than my last office. I never take no for an answer on their second email.

I'd like to say my email full of great things about myself did the trick but I know it didn't. I got back into my prior quality network with my new office and it opens the door to membership to their private insurance plans. They didn't acknowledge my commentary - they simply indicated they had confirmed I was in said quality network roster and here's your new contract. Rates I wanted were inside.

I'll take it. I want the best rates I can get, but what I really need right now is to be able to say "yes I can see that" to referral sources.
 
In somewhat comedic news I received a referral for a "VA" patient except... I don't think I'm in network with the VA. But the referral came from the VA itself. I wrote to the VA/Tricare network asking to participate and they never wrote back. I'm still wrapping my head around insurances not knowing who is and is not in their network. A lady came to my office today claiming United told her we were in network. I'm still not credentialed with Medicare so... how could I be in network.
 
heybrother said:
In somewhat comedic news I received a referral for a "VA" patient except... I don't think I'm in network with the VA. But the referral came from the VA itself. I wrote to the VA/Tricare network asking to participate and they never wrote back. I'm still wrapping my head around insurances not knowing who is and is not in their network. A lady came to my office today claiming United told her we were in network. I'm still not credentialed with Medicare so... how could I be in network.
Click to expand...
Medicare/Medicaid should be pretty quick.

UHC was like offering your first born + the next 3 generations to get on with absolute &%*$ rates.

Lone wolf though so maybe that's why.

Angry doesn't even begin to describe what its like dealing with them and insurances in general.
 
heybrother said:
Renegotiated a contract today to actually be slightly better than my last office. I never take no for an answer on their second email.

I'd like to say my email full of great things about myself did the trick but I know it didn't. I got back into my prior quality network with my new office and it opens the door to membership to their private insurance plans. They didn't acknowledge my commentary - they simply indicated they had confirmed I was in said quality network roster and here's your new contract. Rates I wanted were inside.

I'll take it. I want the best rates I can get, but what I really need right now is to be able to say "yes I can see that" to referral sources.
Click to expand...

For someone trying to learn every little detail/minutia of this crazy system we call US healthcare, can you please explain in simple terms what a "quality network" is? It's so funny because my whole life, I thought it's just PPO, HMO, State medicaid, federal medicare, and that is it.

Now, in the real world, I keep seeing things about IPA, Medicare advantage, fee for service and capitated insurances, etc when I go through the administrative side of my EMR just to learn what the heck is happening and why I can do certain procedures on some people right then and there, and others I have to ask for authorizations, etc even though from what I can tell, it's the same exact insurance.

Not only that, in training, we learned all these Q modifiers that patients have to meet for nail care and callus care. But for a ton of the patients that come through my current practice, for some reason we're allowed to just do nail care on people, regardless of if they meet Q modifiers or not. And apparently we get paid for it so I have no idea how that situation works. lol

It's all so convoluted trying to learn all this. haha
 
footpainhealer said:
... please explain in simple terms what a "quality network"...
Click to expand...
You don't really get a choice. You take the good with the bad - at least initially.

You want to pick an area with high median household income and good insurance overall. Example: my area has a weapons lab with nearly unlimited govt funding (gives all of their employees/families BCBS PPO... so, that's good), and I also have to take MCR and MCA of the area also to fill out my schedule and be on par with PCPs. The work comp and some various other smaller employer plans would be my choice, but I just take them all to make referring to me easy. There are some we avoid, and we just warn them they'll be self pay if they call (rare birds, though).

You can try for a bit more with each plan (and you, or your biller service, should try), but you are going to get about what they pay podiatrists in that area overall. It is worth asking, but it's not as if we have much bargaining power. You are going to get what they give you. Assuming you'd do same services, the difference between picking a good insurance area versus average versus low is basically the difference between working 5 or 10 more years to accomplish same goals. No joke.

Ergo, just try to pick somewhere with 1) good insurance mix overall and 2) little area competition (the first part changes seldom/gradual, but second part can obviously change fast). The other leg of the stool is to 3) be likeable and in touch and visible to PCPs, and you can always control that part. But no, you can't control if a nearby hospital hires a podiatrist, if a strong area group adds an office near you, somebody strong starts solo nearby, etc. And for many areas, if the major govt/industral/agriculture/etc employer shuts down or downsizes majorly, you are typically done... but that's thankfully unlikely (yet should still be evaluated when picking a location: how stable/important the major area employer are to local economy).

heybrother said:
...I really need right now is to be able to say "yes I can see that" to referral sources.
Click to expand...
Yep, this is it. ^^

As a specialist, you have to just be on most/all plans your refer sources take. Make it easy to refer.
If you get busy enough and on long waitlist, you can start to get picky, trim some... but it's a bit of a risk to trim early or trim too many, especially if competition in the area is reasonable or may become strong (so that is 99% of places, for podiatrists having competition).

We are not exactly retina surgeons or colorectal or ortho hand who have rarity, high demand almost anywhere.
 
Last edited:
footpainhealer said:
For someone trying to learn every little detail/minutia of this crazy system we call US healthcare, can you please explain in simple terms what a "quality network" is? It's so funny because my whole life, I thought it's just PPO, HMO, State medicaid, federal medicare, and that is it.

Now, in the real world, I keep seeing things about IPA, Medicare advantage, fee for service and capitated insurances, etc when I go through the administrative side of my EMR just to learn what the heck is happening and why I can do certain procedures on some people right then and there, and others I have to ask for authorizations, etc even though from what I can tell, it's the same exact insurance.

Not only that, in training, we learned all these Q modifiers that patients have to meet for nail care and callus care. But for a ton of the patients that come through my current practice, for some reason we're allowed to just do nail care on people, regardless of if they meet Q modifiers or not. And apparently we get paid for it so I have no idea how that situation works. lol

It's all so convoluted trying to learn all this. haha
Click to expand...
Quality networks are things like Accountable Care Organizations. The hospital in some way tries to render excellent, affordable care thereby saving money and the hospital is allowed to keep some of the savings ...or pay back money in if they cost too much. I'm personally skeptical on some of these things because I don't know that I believe that things that are listed as quality measures are truly associated with cost savings, but - essentially I do PQH-2 screenings, attend a meeting a year and don't have to do anything else for MIPs. Winning? And I get a check for maybe $3-4K a year.

IPA - independent physicians credential together with insurance plans through the organization and to speed up/reward this credentialing process they can be offered superior fee schedules for their members. Feli said it well a long time ago - they can be helpful, but normally they only help you with a couple of plans. Mine help me with Cigna + a bunch of small in town plans and they got me into BCBS in 15 days. In my town they USED to have contracts with every single relevant insurance except United. If I had the plans my IPA lost I would have no bad commercial contracts.

Medicare Advantage - The raping and plundering of our healthcare Medicare system by corporations. Inferior to traditional Medicare in evey single way and a dagger to the throat of your future existence. Facilitated by a political party. Patients on Medicare with part B have to pay for part B but also pay for a supplement, prescription drug plan etc. Private companies offer these services in their place and seek cost savings by reducing reimbursement and limiting care. They then do things like sending nurses to patients homes and boosting the diagnoses in patient's charts to make them look sicker and demand more money from the government. They view podiatrists as inferior providers and negotiate the Medicare fee schedule down paying you less ie. take it or leave it podiatry b&tch. They routinely deny services traditional Medicare wouldn't have questioned and force you to appeal with the end result usually being a continued denial.
 
heybrother said:
Quality networks are things like Accountable Care Organizations. The hospital in some way tries to render excellent, affordable care thereby saving money and the hospital is allowed to keep some of the savings ...or pay back money in if they cost too much. I'm personally skeptical on some of these things because I don't know that I believe that things that are listed as quality measures are truly associated with cost savings, but - essentially I do PQH-2 screenings, attend a meeting a year and don't have to do anything else for MIPs. Winning? And I get a check for maybe $3-4K a year.

IPA - independent physicians credential together with insurance plans through the organization and to speed up/reward this credentialing process they can be offered superior fee schedules for their members. Feli said it well a long time ago - they can be helpful, but normally they only help you with a couple of plans. Mine help me with Cigna + a bunch of small in town plans and they got me into BCBS in 15 days. In my town they USED to have contracts with every single relevant insurance except United. If I had the plans my IPA lost I would have no bad commercial contracts.

Medicare Advantage - The raping and plundering of our healthcare Medicare system by corporations. Inferior to traditional Medicare in evey single way and a dagger to the throat of your future existence. Facilitated by a political party. Patients on Medicare with part B have to pay for part B but also pay for a supplement, prescription drug plan etc. Private companies offer these services in their place and seek cost savings by reducing reimbursement and limiting care. They then do things like sending nurses to patients homes and boosting the diagnoses in patient's charts to make them look sicker and demand more money from the government. They view podiatrists as inferior providers and negotiate the Medicare fee schedule down paying you less ie. take it or leave it podiatry b&tch. They routinely deny services traditional Medicare wouldn't have questioned and force you to appeal with the end result usually being a continued denial.
Click to expand...
Solo PP here, rejoined SDN due to this thread. Couldnt agree more on medicare advantage. I bit%^ constantly about managed medicare. I opened my own practice 7 months ago, just found out im not in humana medicare. They never executed the signed agreement from back in January. I was thinking this whole time "wow humana medicare is actually pretty fair..." when I audited reimbursement rates. Nope! They just werent paying me at 85% of medicare like all the other ones because they never counter signed the agreement and executed the contract. So yea, I wrote to them and rescinded my signature and want to negotiate rates prior to entering into their network. I say my signature when it was a credentialing specialist that signed on my behalf but we wont go there. I am aware of the POA etc etc.

What compelled me to sign up is to ask: Any words of wisdom on negotiating rates with the insurance companies? I am in a smaller college town, "saturated" by insurance standards although I am subspecialized (almost) in doing complex recon and trauma as a dpm (none other do).. Some payers were excellent, most 100% of medicare and some god awful (United.) UHC has me locked in to 3 years according to them before negotiating the robbery of $400 total ankle replacements and I have considered dropping them. I just am so new I didnt want to turn away or make it harder to build volume. Maybe I should make my own post some wheres else but seeing you discuss negotiating contracts got the juices flowing.
 
ownbosswhenleavehouse said:
Solo PP here, rejoined SDN due to this thread. Couldnt agree more on medicare advantage. I bit%^ constantly about managed medicare. I opened my own practice 7 months ago, just found out im not in humana medicare. They never executed the signed agreement from back in January. I was thinking this whole time "wow humana medicare is actually pretty fair..." when I audited reimbursement rates. Nope! They just werent paying me at 85% of medicare like all the other ones because they never counter signed the agreement and executed the contract. So yea, I wrote to them and rescinded my signature and want to negotiate rates prior to entering into their network. I say my signature when it was a credentialing specialist that signed on my behalf but we wont go there. I am aware of the POA etc etc.

What compelled me to sign up is to ask: Any words of wisdom on negotiating rates with the insurance companies? I am in a smaller college town, "saturated" by insurance standards although I am subspecialized (almost) in doing complex recon and trauma as a dpm (none other do).. Some payers were excellent, most 100% of medicare and some god awful (United.) UHC has me locked in to 3 years according to them before negotiating the robbery of $400 total ankle replacements and I have considered dropping them. I just am so new I didnt want to turn away or make it harder to build volume. Maybe I should make my own post some wheres else but seeing you discuss negotiating contracts got the juices flowing.
Click to expand...
1. I'm not 100% what happened to you in regards to Humana. I'm not in network with them.

In general if in network with Medicare AND:
(a) In network with MA Plan - ie. Humana, UHC, Aetna etc -> get paid contractually negotiated rate except you have to constantly check and ensure it happens because they will pay you less than your contract without blinking AND my experience - they deny/screw you every chance they can because you are stuck with the contract which specifies that any complaint/fight goes through some sort of arbitration where you'll lose. You lose even if you win because you had to fight to win.

(b) Out of Network and MA HMO plan - they won't pay. HMO MA patients like HMO everything else has to be seen by in network doctors.

(c) Out of Network and PPO - the doctor gets paid Medicare rates as the "limiting charge" but the patient may be subject to some sort of punishment ie. higher copay, high co-insurance.

I'm currently out of network with all MA plans. A bunch in my area treat me the same in network verse out of network ie. UHC teacher/state employee plans.

Here's my big thing for you though - I've had almost ZERO administrative issues/denials since going OON with MA plans. Since there is no contract there is no document saying they get to sodomize me / dictate the terms of our contractual relationship.

2. In regards to negotiation - I'd love to hear some other people chime in. In general - big plans don't negotiate. I've never been able to get UHC, Aetna, or Humana to negotiate. BCBS doesn't negotiate where I am because they pay everyone the same. Smaller plans negotiate sometimes. Plans that negotiate are more likely to negotiate if you don't give up. Ask for something and if they say no - put together a big I'm awesome email describing all of the things you do. Whenever I've gotten someone to negotiate its always on a 2nd/3rd email. The first email they routinely say screw you. Gotta be willing to walk away though.

Humana, Aetna and United truly are satan though.

*This isn't the first contract thread. We've written some otheres that might be better elsewhere.
 
ownbosswhenleavehouse said:
Solo PP here, rejoined SDN due to this thread. Couldnt agree more on medicare advantage. I bit%^ constantly about managed medicare. I opened my own practice 7 months ago, just found out im not in humana medicare. They never executed the signed agreement from back in January. I was thinking this whole time "wow humana medicare is actually pretty fair..." when I audited reimbursement rates. Nope! They just werent paying me at 85% of medicare like all the other ones because they never counter signed the agreement and executed the contract. So yea, I wrote to them and rescinded my signature and want to negotiate rates prior to entering into their network. I say my signature when it was a credentialing specialist that signed on my behalf but we wont go there. I am aware of the POA etc etc.

What compelled me to sign up is to ask: Any words of wisdom on negotiating rates with the insurance companies? I am in a smaller college town, "saturated" by insurance standards although I am subspecialized (almost) in doing complex recon and trauma as a dpm (none other do).. Some payers were excellent, most 100% of medicare and some god awful (United.) UHC has me locked in to 3 years according to them before negotiating the robbery of $400 total ankle replacements and I have considered dropping them. I just am so new I didnt want to turn away or make it harder to build volume. Maybe I should make my own post some wheres else but seeing you discuss negotiating contracts got the juices flowing.
Click to expand...
Small different take.

1. I'm not in network with UHC commercial.
2. For UHC Medicare advantage - there may be some space between UHC vs Wellmed. Wellmed offered me a better contract awhile back than the UHC contract we started with - wasn't 100% though. That said Wellmed contracts are WAY longer than UHC contracts as opposed to a few years ago and they had way more administrative/trash requirements in them. Things like if they cheat/don't pay you then you can't stop seeing their patients.
 
Advertisement - Members don't see this ad
ownbosswhenleavehouse said:
Solo PP here, rejoined SDN due to this thread. Couldnt agree more on medicare advantage. I bit%^ constantly about managed medicare. I opened my own practice 7 months ago, just found out im not in humana medicare. They never executed the signed agreement from back in January. I was thinking this whole time "wow humana medicare is actually pretty fair..." when I audited reimbursement rates. Nope! They just werent paying me at 85% of medicare like all the other ones because they never counter signed the agreement and executed the contract. So yea, I wrote to them and rescinded my signature and want to negotiate rates prior to entering into their network. I say my signature when it was a credentialing specialist that signed on my behalf but we wont go there. I am aware of the POA etc etc.

What compelled me to sign up is to ask: Any words of wisdom on negotiating rates with the insurance companies? I am in a smaller college town, "saturated" by insurance standards although I am subspecialized (almost) in doing complex recon and trauma as a dpm (none other do).. Some payers were excellent, most 100% of medicare and some god awful (United.) UHC has me locked in to 3 years according to them before negotiating the robbery of $400 total ankle replacements and I have considered dropping them. I just am so new I didnt want to turn away or make it harder to build volume. Maybe I should make my own post some wheres else but seeing you discuss negotiating contracts got the juices flowing.
Click to expand...
Lol 400 TAR amazing
 
Let's be real here. The Medicare price for a TAR in my neck of the woods is already under $1000. Same for ankle fusion. There is no big case that pays well unless you are getting a distribution from an ASC. The money is on the facility side (its an APC 5116 with knees/hips being APC 5115). I'm semi-skeptical he's actually getting $400 for this (I can forgive hyperbole) because if that was the case he'd have essentially a 40% of Medicare contract and would be getting $23 for a plantar fascial injection and $60 for a 11750. The lowest contract I've seen for MA was my own at 65%. UHC seems to like 80-85% of Medicare.

Sign a bad contract. Get bad reimbursement. Always remember though that Medicare has placed an anchor in the ground with their fee schedule rates dragging everything towards $1000 with probably way more data points falling below than above.
 
Hold on wifey I have to go do an uninsured ankle fracture on a 14 a1c. I can’t make it home tonight. No, I won’t get paid. Yes this case might end up in litigation. No, no I have to miss the kids soccer game. Yes, I have to do it I mean this is my chance to get abfas certified so I can have the privilege to do more uninsured ankle fractures that I won’t get paid on!!!! Thank you abfas! You are the GOLD standard. Those ACFAS surveys are totally legit where we all make $450,000+

11 years
$300,000 debt compounding interest
$150,000 jobs when inflation has basic handyman jobs making this much
Higher divorce rates and location constraints

The WORST investment

But those upperline suits were so nice on the interview 🙂 oh dang same upperline suits as the suits at apma. Guess it’s all a scam just like congress.
 
Last edited:
Despite getting older and more jaded with each passing day, I still take on some cases for the love of the game. Sometimes surgery is involved, sometimes it's not. Ego is the wrong word, that would imply I'm doing something for my benefit and not for the patient's. While money influences our decision-making, it has to be about more than just the money.
 
Adam Smasher said:
Despite getting older and more jaded with each passing day, I still take on some cases for the love of the game. Sometimes surgery is involved, sometimes it's not. Ego is the wrong word, that would imply I'm doing something for my benefit and not for the patient's. While money influences our decision-making, it has to be about more than just the money.
Click to expand...
Yes in all seriousness always do what’s best for the patient.

But also in all seriousness never lose yourself to patients or the broken system. Take care of yourself first. Always.

And seeing as this thread is about starting a practice it means hopefully you do your best to remove yourself from a lot of the broken system. Although a lot still exists (I.e reimbursement cuts)
 
Didn't some rule go into effect recently where you must have at least one ADA compliant chair in your office? A lot of these med spa chairs are not ADA compliant. just a heads up
 

Fact Sheet: New Rule on the Accessibility of Medical Diagnostic Equipment Used by State and Local Governments

This fact sheet gives a plain language summary of the technical standards that state and local governments would have to follow to meet their existing obligations under Title II of the ADA.
www.ada.gov www.ada.gov

Are you guys following this? The only chairs that qualify are like the newer midmark/mti chairs. If you take patients weight you need a wheelchair compliant one too.

This is necessary for Medicare too. Ada fines are crazy. This eliminates the medspa chairs
 
BeaverBlade said:

Fact Sheet: New Rule on the Accessibility of Medical Diagnostic Equipment Used by State and Local Governments

This fact sheet gives a plain language summary of the technical standards that state and local governments would have to follow to meet their existing obligations under Title II of the ADA.
www.ada.gov www.ada.gov

Are you guys following this? The only chairs that qualify are like the newer midmark/mti chairs. If you take patients weight you need a wheelchair compliant one too.

This is necessary for Medicare too. Ada fines are crazy. This eliminates the medspa chairs
Click to expand...
So just get one Midmark/MTI for your Diabetties, to use as a procedure chair, and to say you're ADA compliant and then get the cheaper medspa chairs for the other rooms.
 
Boba Foot said:
So just get one Midmark/MTI for your Diabetties, to use as a procedure chair, and to say you're ADA compliant and then get the cheaper medspa chairs for the other rooms.
Click to expand...
ya that’s a good way I believe. Some medspa chairs claim ada compliance though after doing more research. Some claim “Ada friendly” need to just do research.

Mti rep told me his chairs were the only one Ada compliant chairs out there, just disgusting the lies
 
Last edited:
What if you get one that identifies as an ADA chair? I mean it works other places....isn't that discrimination?
 
Got my first summer AC bill - $227. Took down the thermostats and replaced them with Google Nests. Just finally figured out how to truly control the scheduling. Thought I had it right, but dang things kept jumping to Eco during the day. One of the units was also kicking on for the weekend and I fixed that. Office feels a lot more comfortable at 72 than 74F.

Have switched all in office transactions from Healow Pay at 3.5% + $0.30 to Square at 2.6% + $0.15.

Looking into getting Helcim for credit card transactions at like 0.4% + $0.08 over interchange, but we still have so few transactions that it doesn't really matter. Paying for the credit card reader would eat whatever savings we might make... or different take. The sooner you switch, the sooner you start paying off the reader.

Still filling out the schedule makes it easy to pick up same days and cash pays which has been nice, but I saw quite a bit of pus today.

Still waiting on Medicare money'$ to hit the bank account so I can break even. Want to ask my business credit card for a limit increase cause I'm sick of paying the damn thing off, but waiting for that money to post so my income looks higher.

There's an awesome local payor in my town that is having a committee meeting about me this week. Can't wait for that to go through as they pay solidly over Medicare.

Running on 2 staff. My ex-partner has 4. Wonder how that's going for him.

Learning so much about where credit card fees apply and don't.

Still no paycheck. Womp womp.

Spent hours this weekend poisoning weeds growing in parking lot and cutting them down with weedeater. Mud kept settling in the "gutter" in front of my office and then plants would grow in it so I hauled the mud off. Need to repair asphalt in parking lot so weeds can't take root.

Still waiting on real estate to rain easy money on me like mana from heaven.

Still happier being on my own.
 
heybrother said:
Spent hours this weekend poisoning weeds growing in parking lot and cutting them down with weedeater. Mud kept settling in the "gutter" in front of my office and then plants would grow in it so I hauled the mud off. Need to repair asphalt in parking lot so weeds can't take root.
Click to expand...
Check your roof
Last thing you want is an in-office water feature with a full day of patients.
 
Advertisement - Members don't see this ad
BeaverBlade said:

Fact Sheet: New Rule on the Accessibility of Medical Diagnostic Equipment Used by State and Local Governments

This fact sheet gives a plain language summary of the technical standards that state and local governments would have to follow to meet their existing obligations under Title II of the ADA.
www.ada.gov www.ada.gov

Are you guys following this? The only chairs that qualify are like the newer midmark/mti chairs. If you take patients weight you need a wheelchair compliant one too.

This is necessary for Medicare too. Ada fines are crazy. This eliminates the medspa chairs
Click to expand...
Didn't read all the fine print, but the rule seems to apply to "State and Local Governments". So does this mean it applies to private practices? Some of the language:
  • The rule generally requires all MDE that state and local government entities purchase, lease, or otherwise acquire after October 8, 2024 to be accessible, until the entities have the amount of accessible MDE specified in the rule.
 
Creflo said:
Didn't read all the fine print, but the rule seems to apply to "State and Local Governments". So does this mean it applies to private practices? Some of the language:
  • The rule generally requires all MDE that state and local government entities purchase, lease, or otherwise acquire after October 8, 2024 to be accessible, until the entities have the amount of accessible MDE specified in the rule.
Click to expand...
I don't think a pp is a government entity.
 
Weirdy said:
Check your roof
Last thing you want is an in-office water feature with a full day of patients.
Click to expand...
The building got a new roof right before I purchased it. However, it immediately had a substantial leak that ruined the panels at the front-check in receiption area. They had to come out again and do some repairs and replace the panels. Still watching/waiting to see if any other panels have problems.

The roof was paid for by the prior owner/insurance company which generates a problem - the roofing company never interacted with me and therefore they don't care about me. Its like being in a global except the doctor ignores you. They literally sent someone out who looked at the roof, realized there was a broken feature that still needed to be repaired, and then instead of coming in or calling me to let me know what was happening they just left and never spoke to me. I had to call back a few days later to get them to admit they were still working to repair it and waiting on parts. I was super excited about getting the new roof and the realtor assured me it was a very expensive/fancy roof that would stand up to hail etc, but its somewhat been a bummer. Supposedly the insurance company paid $65K.
 
Creflo said:
Didn't read all the fine print, but the rule seems to apply to "State and Local Governments". So does this mean it applies to private practices? Some of the language:
  • The rule generally requires all MDE that state and local government entities purchase, lease, or otherwise acquire after October 8, 2024 to be accessible, until the entities have the amount of accessible MDE specified in the rule.
Click to expand...
only if you receive payments from medicare/medicaid i believe if you're private practice.
1784731926651.png


TLDR: you need at least one ADA Compliant treatment chair(more than one if you have 10+). if you take patients weights you need it to be wheelchair accessible (it costs a ton, so my suggestion is just ask patients their weight but IDK)
 
Last edited:
Weirdy said:
Looks like I was wrong.
Runs in the same vein as DME license for Medicare/medicaid reimbursements.

You will need a chair that's compliant.
Click to expand...
yes and expect MTI to brag about how they're compliant while jacking up the prices even more. i'm researching which medspa chairs can be considered ADA compliant. reached out to some companies personally and talked to a ceo of a large medspa chair company and he kept calling his chair "ada friendly" when i pushed him on if it was ada compliant. so i assumed that's a no.

ariachairs.com

LANDON Electric Podiatry Chair – ADA Compliant, UL & FDA Listed

ADA-compliant & UL listed electric podiatry chair with removable foot section, Trendelenburg positioning, microfiber upholstery, and 4 motor adjustment for modern foot care clinics.
ariachairs.com ariachairs.com

this one claims to be ADA compliant but i'm trying to have them verify.

i think chairs are probably the biggest cost when starting an office. if you can slash that cost in half you can have way more runway to profitability and also maybe just more office decor etc. a new MTI chair with shipping etc is gonna be around $11k
 
Last edited:
BeaverBlade said:
yes and expect MTI to brag about how they're compliant while jacking up the prices even more. i'm researching which medspa chairs can be considered ADA compliant. reached out to some companies personally and talked to a ceo of a large medspa chair company and he kept calling his chair "ada friendly" when i pushed him on if it was ada compliant. so i assumed that's a no.

ariachairs.com

LANDON Electric Podiatry Chair – ADA Compliant, UL & FDA Listed

ADA-compliant & UL listed electric podiatry chair with removable foot section, Trendelenburg positioning, microfiber upholstery, and 4 motor adjustment for modern foot care clinics.
ariachairs.com ariachairs.com

this one claims to be ADA compliant but i'm trying to have them verify.

i think chairs are probably the biggest cost when starting an office. if you can slash that cost in half you can have way more runway to profitability and also maybe just more office decor etc. a new MTI chair with shipping etc is gonna be around $11k
Click to expand...
Typical racketeering stuff
 
BeaverBlade said:
yes and expect MTI to brag about how they're compliant while jacking up the prices even more. i'm researching which medspa chairs can be considered ADA compliant. reached out to some companies personally and talked to a ceo of a large medspa chair company and he kept calling his chair "ada friendly" when i pushed him on if it was ada compliant. so i assumed that's a no.

ariachairs.com

LANDON Electric Podiatry Chair – ADA Compliant, UL & FDA Listed

ADA-compliant & UL listed electric podiatry chair with removable foot section, Trendelenburg positioning, microfiber upholstery, and 4 motor adjustment for modern foot care clinics.
ariachairs.com ariachairs.com

this one claims to be ADA compliant but i'm trying to have them verify.

i think chairs are probably the biggest cost when starting an office. if you can slash that cost in half you can have way more runway to profitability and also maybe just more office decor etc. a new MTI chair with shipping etc is gonna be around $11k
Click to expand...
My new hospital office bought bariatric chairs for me. 13k for 2 with shipping. 11k for 1 is crazy.
 
Advertisement - Members don't see this ad
air bud said:
Lol 400 TAR amazing
Click to expand...
Biggest joke is that when the sh$t hits the fan they can turn around and file a malpractice case and get $$$. Every time you take a patient to the OR you are increasing your risk all to make less than a plumber.
 
apollofx said:
Biggest joke is that when the sh$t hits the fan they can turn around and file a malpractice case and get $$$. Every time you take a patient to the OR you are increasing your risk all to make less than a plumber.
Click to expand...
I mean it's really true. Honestly at this point There's not much value in being 4 ft only. Unless you're being unethical and doing a 4-ft slam on everybody doing a bunion or a neuroma or a couple hammer toes, once you throw in a global there's no way it's worth it.... Unless you're doing hind and ankle and larger recons There's just no way surgery is worth it. You're going to make way more money seeing patients in clinic not dealing with global periods.
 
1. When dealing with Traditional Medicare - 28299 or 28297 only needs 2x 28285 to equal out to an ankle fusion. Since I have started practicing the reimbursement for an ankle fusion has fallen from a bit over a $1000 to right at $900 and it will fall further next year.
2. All insurance reimbursed surgery likely reimburses at below the associated liability.
3. The best reimbursing surgery is a multi-procedure cases with additional procedures that don't change the global - like MIS osteotomies and hammertoes. Except Aetna reimburses the 3rd procedure at 25% and at 25% nothing is worth doing
4. Its probably not worth operating in private practice unless you have a high volume of commercial/state/federal BCBS cases that can be performed at an ASC.
5. From a private practice owner perspective where I'm now keeping 100% of my profits (so.. nothing a present 🤔) - assuming that the surgery cases didn't interfere with the ability to see clinic patients - the question simply becomes - would you rather have $10-20-50,000 or whatever you collect extra at the end of the year after overhead. If you keep anything that exceeds overhead then all dollars are not equal in their effort of collection but they are still dollars you otherwise would not have had.
 
air bud said:
I mean it's really true. Honestly at this point There's not much value in being 4 ft only. Unless you're being unethical and doing a 4-ft slam on everybody doing a bunion or a neuroma or a couple hammer toes, once you throw in a global there's no way it's worth it.... Unless you're doing hind and ankle and larger recons There's just no way surgery is worth it. You're going to make way more money seeing patients in clinic not dealing with global periods.
Click to expand...
In PP, any surgery for well-insured patients is pretty viable if you can do them fast and schedule them in a block set. Even if you do a neuroma, then Lapidus/Akin, then Lapidus + Weils, then maybe Haglund... good day. Those are great for the ASC or hospital, and they're good for the doc. They'd be happy with 5th hammertoe followed by warts in OR followed by Austin followed by plantar fascia release... fast cases, good insurance.

The surgery CPTs themselves pay ok (with good insaurance it pays good, but global makes it ok), but the DME and the high level visits pay well. The part that makes it only ok overall is the associated paperwork for work letters, FMLA, short term disab, office staff doing prior auth, etc etc.

The trauma and pus bus "limb salvage" is what usually kills you (for PP)... those patients have less/no insurance, and they are higher risk to sue.
(work comp injuries can be ok if you have good billers who will get most of it)

Ideally, you'd want all ingrowns, warts, injects, non-op fractures for most $ and least stress in PP... yeah. But to be full in office, you typically have to take all comers... but the surgery can pay fine as long as you are efficient with it. I will do the recur bunions or flat foot or bimall, etc... the surgery does pay fairly well.

...I will give credit to any PP that tries to make it on wounds, inpatient pus consults, stuff like that... basically doing hospital DPM work - but as a PP doc. That is a very grindy way to make a DPM living with a lot of zero pay cases and bad hours. A lot of the cases start late as add-on, but a lot of podiatrists do that stuff... mostly in saturated areas and at hospitals that don't have a DPM employ, but it's everywhere (in PP, in supergroup, Msg, ortho group, etc). Terrible work imo.

heybrother said:
...4. Its probably not worth operating in private practice unless you have a high volume of commercial/state/federal BCBS cases that can be performed at an ASC. ...
Click to expand...
Basically, yes.

It doesn't really matter if ASC or hospital... as long as it's close or even same roof as your office (I lease suite in small hospital). Good payers + Efficiency = ftw.

It is absolutely not worth driving awhile to do a case or two (even if the pts are well insured). It might be worth driving to do 3+ cases, but still need to try to do them closer and with good turnover times.
 
@Feli I agree with everything you say besides one thing

I think the higher risk patients malpractice wise is definitely the elective cases not the limb salvage cases. If you have a mri showing OM and you amp it is what it is. And if they’re diabetic and it doesn’t heal? It is what it is.

The 18 year old elective bunion is way higher risk if they end up with a nonunion/revision surgery or varus or whatever.

Just my thoughts.
 
You must log in or register to reply here.

Similar threads

BeaverBlade
Podiatry Proof
Replies
6
Views
915
Bored Snorlax
Bored Snorlax
S
Podiatry Surgery Volume
2 3
Replies
131
Views
5K
Hybrocure
Hybrocure
air bud
Podiatry Song Parodies
Replies
13
Views
861
Feli
Feli
HalluxSlicer
Rise of Mid-Level Podiatry
Replies
11
Views
449
Sybly
S
A
The Future of Podiatry
Replies
44
Views
4K
Homo sapien
Homo sapien