Costs and figures... startup Solo podiatry office

[BubbaWub]

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Go get em.

I've got a surplus of podiatrists around me.
When I first came to town I reached out to 4 or 5 nursing homes/ assisted living/ LTC facilities. All 5 told me to kick rocks.
Had a CEO via their secretary tell me "We already have a podiatrist." and nothing else, just radio silence.

Really rooting for you and the other 2 who just opened up shop.

The nursing home contracts that I have are exclusively for myself.

The level of care and relationship I have fostered with these homes over the years is something you can't really build overnight. I know the manager's son, wife, etc. We have taken family excursions to our local Golden Corral. Our wives are part of the same yoga class, etc.

Believe me when I say, you will not be able to take these nursing home contracts away from me. They are locked in.

I have had some new grads reach out to me trying to squeeze their way into my nursing homes. It's not happening. When I pass, maybe they can have them, but until then they prove to be one of the most lucrative parts of my practice. I would wager that the money I get from a week worth of nursing homes is far more than any foot & ankle surgeon can make in the operating room.

Thank you

 

[BeaverBlade]

Ouch. Have we reached nursing home toenail clipping saturation?

Think it’s the opposite. There’s a ton of foot nurses now doing toenails because we have lost the corner on the market. I have one near me even advertising Google ads as “podiatrist trained nurse” and “conservative management of ingrown nails” not sure what it means

 

[heybrother]

I actually had a patient's sister come with her on an encounter to try and ask me if I'd come work at her nursing home.

It was as flattering as Zach Jungles telling me what a great surgeon I am 😎

 

[Weirdy]

The nursing home contracts that I have are exclusively for myself.

The level of care and relationship I have fostered with these homes over the years is something you can't really build overnight. I know the manager's son, wife, etc. We have taken family excursions to our local Golden Corral. Our wives are part of the same yoga class, etc.

Believe me when I say, you will not be able to take these nursing home contracts away from me. They are locked in.

I have had some new grads reach out to me trying to squeeze their way into my nursing homes. It's not happening. When I pass, maybe they can have them, but until then they prove to be one of the most lucrative parts of my practice. I would wager that the money I get from a week worth of nursing homes is far more than any foot & ankle surgeon can make in the operating room.

Thank you

Sir, this is a Wendy's.

 

[dtrack22]

Oh word? I need to go holler at the closest county jail!!!!

Prison ≠ Jail. Need a state or federal correctional facility.

 

[Stormblest]

It may be kinda wrong but when I read any of Bubbawubs post, in my head I automatically read it with an exaggerated African accent that you would hear in the movies

 

[Feli]

Very location dependent. I had a BCBS contract at 180% Medicare, UHC was my worst commercial payer at 130% Medicare. And MA plans were 100% Medicare. Prison insurance payed 2x Medicare for inmates…cha-ching…for the most part this was true for both E/M and CPT codes.

Correct.

The smart play is to hire a biller/cred service that knows the area, let them do their thing... get you onto plans, negotiate where they can, tell you which ones you should not take. It's pointless to do all this work oneself (unless you enjoy it?). It's very area-specific, but not all areas are wasteland (some are).

Basically, give the dough to the baker... doc job is to see more pts, do more procedures/dme. The cred work is nails on a chalkboard for me.

 

[Boba Foot]

Prison ≠ Jail. Need a state or federal correctional facility.

I did a TMA on prisoner a year or two ago. Got paid more than a bunion and never had to see the guy again. It was great.

 

[eyeeye_captain]

Fun fact: one eye residency got a good chunk of their surgical volume operating literally inside a state prison until maybe a couple years ago.

 

[heybrother]

When I was a resident, one of my attendings left a hospital job to start their own thing. There was a question about whether their patients were all "new" now that they were being seen on a new tax ID. AI says the new/established distinction follows the doctor, not the TIN.

I can tell you that from accidentally billing new codes on a few people - that insurance has 100% been denying these if we were already established.

I'm in no way fretting or bothered by this - I'm simply telling you that you'll have to keep track of this because you'll end up having to resubmit if you don't catch this on an established patient.

 

[BeaverBlade]

When I was a resident, one of my attendings left a hospital job to start their own thing. There was a question about whether their patients were all "new" now that they were being seen on a new tax ID. AI says the new/established distinction follows the doctor, not the TIN.

I can tell you that from accidentally billing new codes on a few people - that insurance has 100% been denying these if we were already established.

I'm in no way fretting or bothered by this - I'm simply telling you that you'll have to keep track of this because you'll end up having to resubmit if you don't catch this on an established patient.

But the insurances make it location based when they make us get recredentialed with the same insurances when we leave a job how convenient

 

[heybrother]

But the insurances make it location based when they make us get recredentialed with the same insurances when we leave a job how convenient

I'm not claiming its a good system. I'm just telling you that if you plan on hitting everybody with a 99203/99204 that you'll be refiling a lot of claims 😉

 

[Feli]

Guys, when a 99214 pays more than a 99203 anyways, do you really care? 🙂

(yeah, you lose a bit on ones that would've been a 99204, but that's not many)

 

[Aresnebula]

As someone who eventually wants to start solo, how did you guys go about proctoring for surgeries? I am not board certified yet and it will take a while I assume. Current practice, my colleague proctors me.

 

[heybrother]

As someone who eventually wants to start solo, how did you guys go about proctoring for surgeries? I am not board certified yet and it will take a while I assume. Current practice, my colleague proctors me.

Never had to be proctored. Kind of mind blowing to me what some people have to go through.

Like everytime someone on here says "We have to get authorization for an clinic injection or nail surgery" I think - WTF- I pursue authorization on zero in clinic procedures.

 

[air bud]

Guys, when a 99214 pays more than a 99203 anyways, do you really care? 🙂

(yeah, you lose a bit on ones that would've been a 99204, but that's not many)

Pretty sure you should be at least 35ish percent new level 4...

 

[Mia McBhul]

As someone who eventually wants to start solo, how did you guys go about proctoring for surgeries? I am not board certified yet and it will take a while I assume. Current practice, my colleague proctors me.

wtf? how insulting?about how long have you been practicing for?

 

[Feli]

Pretty sure you should be at least 35ish percent new level 4...

For some stuff, yeah (DM exams, multiple CCs, old surgery, etc).

But for the majority of PP pts (ingrown... now other foot, had PF at old office... have it again at new, RFC, new orthotics, whatever) the 99214 is actually better than the -203.

 

[Feli]

Never had to be proctored. Kind of mind blowing to me what some people have to go through.

Like everytime someone on here says "We have to get authorization for an clinic injection or nail surgery" I think - WTF- I pursue authorization on zero in clinic procedures.

As someone who eventually wants to start solo, how did you guys go about proctoring for surgeries? I am not board certified yet and it will take a while I assume. Current practice, my colleague proctors me.

It's not the proctoring, it's the hospital privi/apps that gets you when solo. That should be a non-issue. If hospital wants that, they can provide it (from what I've seen, only in some super-saturated metros).

... the real issue is that you need at least a few references from DPMs in the area, sometimes need "backup call coverage" for some facilities apply/renew, stuff like that.

 

[Aresnebula]

wtf? how insulting?about how long have you been practicing for?

It is only for surgeries at the surgery centers/hospitals. They are the ones who asked for it. Few months into practice.

 

[footpainhealer]

It is only for surgeries at the surgery centers/hospitals. They are the ones who asked for it. Few months into practice.

I was under the impression that it is normal for the first few cases to be proctored anytime we join a new hospital.
I had to as well for 4 different hospitals that our group takes call at.

 

[Weirdy]

I was under the impression that it is normal for the first few cases to be proctored anytime we join a new hospital.
I had to as well for 4 different hospitals that our group takes call at.

Might be location dependent.

I did not have proctors for case types > a certain # of reps from surgery logs.

There were a few that would require proctoring if hospital deemed not enough reps. Mostly crazy rearfoot or soft tissue flap stuff.

 

[Adam Smasher]

I was under the impression that it is normal for the first few cases to be proctored anytime we join a new hospital.

I'm going to try my best to be nice. Because there certainly isn't shame in asking a colleague for help.

But as a matter of fact, what's normal is for licensed surgeons to be able to operate independently upon completion of post graduate training without the need for double-scrubbing. What's normal is for surgeons to be able to self-assess and decide for themselves what cases they should and shouldn't be taking on. What's normal is for baby bird to fly from the nest.

And I understand that podiatry isn't normal in this regard, and if you take exception to what I've written, I apologize that your residency director and really this profession have failed you.

 

[air bud]

I was under the impression that it is normal for the first few cases to be proctored anytime we join a new hospital.
I had to as well for 4 different hospitals that our group takes call at.

Maybe as a new grad.....sounds like a lot of TFPs around town ...

 

[footpainhealer]

I'm going to try my best to be nice. Because there certainly isn't shame in asking a colleague for help.

But as a matter of fact, what's normal is for licensed surgeons to be able to operate independently upon completion of post graduate training without the need for double-scrubbing. What's normal is for surgeons to be able to self-assess and decide for themselves what cases they should and shouldn't be taking on. What's normal is for baby bird to fly from the nest.

And I understand that podiatry isn't normal in this regard, and if you take exception to what I've written, I apologize that your residency director and really this profession have failed you.

haha dude I think you're misconstruing what happened.

No one is watching or helping me operate. The hospitals just required that 3 cases are "proctored" with the owner of the practice there. They popped in, signed the form, and left before the timeout was even done lol.

It's a hospital policy thing AFAIK. They even have forms for the new general and ortho surgeons that started here and have to be proctored.

 

[DYK343]

My last hospital job (fresh out residency) required 10 cases proctored.

This was the same for all surgeons. Even if out of residency awhile.

Its regional but its a thing

I remember having to proctor other surgeons. It was wasted time and annoying. Ortho had to proctor a bunion surgery for me. I had to proctor an ortho ankle fx - who was a traumatology trained fellow. This was his 2nd job too. So it wasnt just new grads.

Where I am at now I didnt have to do any proctoring.

 

[Toenail]

My last hospital job (fresh out residency) required 10 cases proctored.

This was the same for all surgeons. Even if out of residency awhile.

Its regional but its a thing

I remember having to proctor other surgeons. It was wasted time and annoying. Ortho had to proctor a bunion surgery for me. I had to proctor an ortho ankle fx - who was a traumatology trained fellow. This was his 2nd job too. So it wasnt just new grads.

Where I am at now I didnt have to do any proctoring.

Hospital employed. Not first job and had to be proctored which was understandably ultra annoying for my colleagues with respect to their time. So I teed up some amps from call and they proctored 10 cases at 10 minutes each and then after that I resumed doing blown out ankle fractures and elective recons.

 

[Stormblest]

No proctoring for me fresh out of residency at my place. Just wanted logs from residency.

 

[BeaverBlade]

No proctoring for me fresh out of residency at my place. Just wanted logs from residency.

Same. That would’ve made me way more nervous than I already was..

 

[josebiwasabi]

I was also proctored when I started my 1st job and also my current job in two different states. I think it was a total of 5 cases at each hospital? But for both, it was based off of XR and chart review (ie appropriate documentation, indications for surgery, appropriate fixation etc), not someone scrubbed into my case or even physically observing my surgery. Other specialties at my hospital undergo the same process.

 

[air bud]

Yeah to be fair, I think technically I got proctored for my newest job but that just involved ortho reviewing like 10 OP reports and that was it. Wasn't in the room I just sent 10 cases and they looked at my paperwork paperwork

 

[Adam Smasher]

The reason I wrote my post above is because a few years ago I had another podiatrist who was about 5 years out join the hospital and he asked me to proctor him. He had about 50 case logs (!) and wanted to learn how to do lapidus bunionectomies so he could get ABFAS certified before he hit the deadline. I told him fine, I'm no virtuoso at it but I'll show you. He then became increasingly insistent that he wanted me to help him reach a specific benchmark before I stopped proctoring him. At that point I told him, "Look, I'll help you but I can't be your residency director. You have to be able to do these on your own at some point."

For some reason I didn't hear from him since.

 

[BeaverBlade]

Just got my first:

“You don’t have a dremel?”

 

[heybrother]

1. The manager at my last office was tragically pulled into a dremel and we had to get rid of them all after the investigation.
2. My father was a podiatrist and he died of onychomycotic lung after breathing in too much dremel nail fungus.
3. The dremel makes a subsonic noise which is only perceptible to my ear, but is extremely painful.
4. This is a brand new office and we haven't bought one yet because of the Canadian dremel market tariffs.
5. I don't own one. Its gross. They put debris into the air. I do surgery here and I don't want to contaminate my office. I think you'll do fine with debridement. There's a boomer down the street who can help you if this is something you really need.

 

[BeaverBlade]

4. This is a brand new office and we haven't bought one yet because of the Canadian dremel market tariffs.

this is the one. amazing thank you sir.

 

[Mia McBhul]

Just got my first:

“You don’t have a dremel?”

By no means to I enjoy cutting toenails or dremeling. I dont think any one of us anticipated this when going into podiatry, we were all sold that we will be doing badass orthopedic surgery all day....but the reality is grim and if the other practices in town are all dremeling, then I will too! I hate it, its too humbling of work to do, but to stay competitive in whichever market we're in, I dont think there's much of an option.

 

[BeaverBlade]

By no means to I enjoy cutting toenails or dremeling. I dont think any one of us anticipated this when going into podiatry, we were all sold that we will be doing badass orthopedic surgery all day....but the reality is grim and if the other practices in town are all dremeling, then I will too! I hate it, its too humbling of work to do, but to stay competitive in whichever market we're in, I dont think there's much of an option.

I kind of don’t even want nailcare business. It’s looking like (and I hope it stays that way) I might be busy without it and they are finding me regardless. I feel like it’s just a PITA to get it covered a lot of times. I’ve had a few who just show up and want it covered with nothing wrong

The few I’ve seen so far don’t even qualify.

 

[Feli]

By no means to I enjoy cutting toenails or dremeling. I dont think any one of us anticipated this when going into podiatry, we were all sold that we will be doing badass orthopedic surgery all day....but the reality is grim and if the other practices in town are all dremeling, then I will too! I hate it, its too humbling of work to do, but to stay competitive in whichever market we're in, I dont think there's much of an option.

It is just much preferrable to have some RFC in the mix... as opposed to having 20-30pts/d of all fractures, deformities, pre/post op, wounds/infections.

That stuff is viable for hospital pods or in an ortho group with PAs and high staffing, not so good for a podiatry PP (financially).

You want a mix (RFC, derm, sports med, fract/ortho, wound/DM, elective OA/deformities) just so it's not boring. But you don't need all hard visits every day. So, the natural solution is to market mainly for the deformity/injuries/sports/derm stuff... the wounds and DM and RFC find you naturally (take it, but don't encourage it)

The notes, stress, associated paperwork with all MSK stuff is not ideal, imo. That's not to even mention all the low/no insured injuries and wounds. I send 80% or more of the fracture refers I get from ERs and UCares to other nearby DPMs lately... not joking. We sent a Jones fx refer to nearby hospital employ podiatrist instead about 10min ago today. It's nothing I can't do, but I am legit packed already... and honestly, the chances of a 24M injury pt not being a headache, probably poor insured, etc... so yeah, they can have fun and "get numbers." And sure, I sound old saying that, but I'd rather have a follow-up MCR + secondary insured RFC or DM exam pt in that spot. Yep, I said it...

 

[Stormblest]

I see basically zero nails and I thought I would never say this, but sometimes I wish I could just have an easy mindless nail visit a couple of times a day.

 

[heybrother]

My morning was set to be all nails today. So at 11:30 a guy I used to see at my last office walked in with a cellulitic hallux with a wound that probed 2.5cm. High as a kite. Smells like a toilet.

My MA is pissed. I'm going to have to buy breakfast tomorrow.

 

[Mia McBhul]

My morning was set to be all nails today. So at 11:30 a guy I used to see at my last office walked in with a cellulitic hallux with a wound that probed 2.5cm. High as a kite. Smells like a toilet.

My MA is pissed. I'm going to have to buy breakfast tomorrow.

and this little piggy goes BYE BYE!!!

 

[dtrack22]

It is just much preferrable to have some RFC in the mix... as opposed to having 20-30pts/d of all fractures, deformities, pre/post op, wounds/infections.

Nothing wrong with some routine foot care. However, those patients are like gremlins. They multiply. What started as two RFC appointments per day turns into four, turns into six, until it becomes half of your clinic four days a week. Now, you only have 10 to 15 available available appointment slots for acute problems, procedures, surgical patients, etc.

PCPs have zero understanding of what is actually covered, or what diagnosis qualify the patient for care. Once you begin accepting routine foot care referrals, and keeping those patients in your clinic, the floodgates open and the referrals for people who simply can’t reach their toes start pouring in. You will ultimately have to do some education with your referral sources on who actually qualifies for their free Medicare pedicure. Otherwise, you will quickly become overrun with nail care referrals.

 

[BeaverBlade]

Nothing wrong with some routine foot care. However, those patients are like gremlins. They multiply. What started as two RFC appointments per day turns into four, turns into six, until it becomes half of your clinic four days a week. Now, you only have 10 to 15 available available appointment slots for acute problems, procedures, surgical patients, etc.

PCPs have zero understanding of what is actually covered, or what diagnosis qualify the patient for care. Once you begin accepting routine foot care referrals, and keeping those patients in your clinic, the floodgates open and the referrals for people who simply can’t reach their toes start pouring in. You will ultimately have to do some education with your referral sources on who actually qualifies for their free Medicare pedicure. Otherwise, you will quickly become overrun with nail care referrals.

That’s why I’m trying to prn a lot of them even though I’m a new practice because I can see the schedule being full at current volume if it continues…

Nail care takes a lot of time… takes forever to get the patients in the chair, etc (only have one other staff currently)

 

[Toenail]

Nothing wrong with some routine foot care. However, those patients are like gremlins. They multiply. What started as two RFC appointments per day turns into four, turns into six, until it becomes half of your clinic four days a week. Now, you only have 10 to 15 available available appointment slots for acute problems, procedures, surgical patients, etc.

PCPs have zero understanding of what is actually covered, or what diagnosis qualify the patient for care. Once you begin accepting routine foot care referrals, and keeping those patients in your clinic, the floodgates open and the referrals for people who simply can’t reach their toes start pouring in. You will ultimately have to do some education with your referral sources on who actually qualifies for their free Medicare pedicure. Otherwise, you will quickly become overrun with nail care referrals.

My group solved the RFC plague by only allowing new RFC patients that have a history of an amp or DFU.

Here is a picture representing how our front desk deals with the horde of RFC referrals:

 

[BeaverBlade]

What’s a good alternative to diabetic shoes if I don’t want to offer them at my practice for patients who need them?

(Didn’t know if TFP thread or this one)

 

[Feli]

What’s a good alternative to diabetic shoes if I don’t want to offer them at my practice for patients who need them?

(Didn’t know if TFP thread or this one)

Rx them to ortho store (Hanger, etc). That is the best way to do it unless you have a lot of space and staff and the inclination to do shoes... and audits.

DM shoes are a storage, audits, customer service (just like orthotics), staff time, etc etc problem.

It's fine to get paid for the exams/visits, write the Rx, and let somewhere else do the shoes/insoles. (they'll do a better job than you anyways)

 

[air bud]

What’s a good alternative to diabetic shoes if I don’t want to offer them at my practice for patients who need them?

(Didn’t know if TFP thread or this one)

Tfp thread

Fitville and some Inoceps



Orthofeet are trash now....cheap and expensive.

 

[Weirdy]

Tfp thread

Fitville and some Inoceps



Orthofeet are trash now....cheap and expensive.

Dam and I thought you weren't TFP anymore.

Lowkey taking notes though

 

[BeaverBlade]

Dam and I thought you weren't TFP anymore.

Lowkey taking notes though

There is a TFP deep down in every podiatrist.

 

[Adam Smasher]

I do a LOT of shoes. Prior to joining my group, my partner trained the staff on this. Personally, I just tick off boxes and sign a set of forms in 3 places and that's the extent of the work I do. Unfortunately, I can't change the system and I've become a part of it.

With respect to staff time: they'd just spend the time scrolling their phones so idgaf
With respect to storage: I have the space, but a lot of vendors are switching over to 3D scanner apps which saves on foam boxes
With respect to audits: my partner used to do a lot of custom molded shoes (A5501 not A5500) and those were the only things we got audited on. I dunno, maybe I'm due.
With respect to customer service: patients get 2 retries before they're banned for life

I think I posted elsewhere our group's profit in 2025 was about $75k off shoes alone. You decide if you want to give it to Hanger.