First 2 weeks in Practice

[Rogue990]

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I'm losing approximately 25k a year, haha. I thought this post was fairly anonymous. Regardless, I was looking for a general idea of what one can expect the first few years in practice, not an exact amount.

 

[GSresident]

Its really hard to estimate what my income will be at this point. I know exactly how many RVU's I have done for July and August. The problem is I don't know what the average $/RVU will be for this area. I still have yet to see an uninsured patient. I have only seen 2 medicaid patients. A minority of my patients are medicare at this point. The majority are Blue Cross and other private insurances.

The other thing is that I have all of these bills to submit but no way to submit them just yet. I am working with an independent contractor to be able to submit bills. I should be able to do that within 2 weeks.

My income in July was $85. That came from copays, but like I said I haven't billed for my services yet. That figure should be a bit of a wake up call for people. There really isa fairly significant delay between when you start and when you actually get paid.

I'm doing pretty well for practice growth so far. I did 4 times the RVU's in August that I did in July, and I was gone a week in July. September is looking good because I have started getting the pre-approval letters back for panniculectomies. I did one last week but I did an abdominoplasty and the patient will make up the difference in cost. The OR nurse who scrubbed with me that day walked out to the scheduling desk after the case and scheduled hers for next monday. I also have a bunch of stuff from the wound care center, some blephs to do and the random recon stuff that I get from ortho and trauma. Things are looking good. Once I get my billing up to speed I should be in a lot better shape financially.

 

[droliver]

Kyle,

Check with some of your carriers re. online pre-authorization for some surgeries. BCBS of Alabama now has an online form we can fill out for panniculectomy, breast reduction, & septoplasty where approval is nearly immeadiate instead of the 4-6 weeks previously. You do have to sign an affadavit re. truthful answers and they reserve the right to review charts post procedure (so you better have your ducks in a row). It's convenient, but they've put some of the risk on you financially.

 

[maxheadroom]

What do you need for the septos? Just documentation about failing "conservative" treatment with nasal sprays and allergy meds? Do you need a sinus CT showing obstruction?

 

[GSresident]

This is a gigantic adjustment. It is even more of an adjustment than I had anticipated. I have been having nightmares of being stuck in quick sand. I feel like I have so much more to offer and that I am being under-challenged right now. As soon as I start collecting I am going to expand to a major metropolitan area. As much as I love the Normal Rockwell practice in a small town, I don't feel like I am being challenged. I'm driving around in 1st gear with 900 hp waiting to be gassed. I'm writing this 2 days after having my biggest day ever - about 200 RVU's, and 2 days before I am expecting a new baby. What the hell is wrong with me!??!?

In other news, I had a new experience over the last couple weeks. I have interviewed half a dozen people for a secretary job after one of my less-than-stellar employees quit during the middle of the day secondary do a bout of diarrhea. If you only knew.

 

[GSresident]

I'm on my way to a meeting with the CEO of another hospital. I am establishing another satellite clinic today. This morning I entered talks with the CEO of a major metropolitan hospital to quote "sell" my practice. Its still very early in the process and I really enjoy my independence. I wouldn't "sell" for less than a jaw dropping amount at this point but who knows, maybe we can work something out.

 

[pyromatic]

Forgive my ignorance, but when you sell your practice, are you essentially becoming a salaried employee for a large sum of money?

 

[GSresident]

That is more or less correct. There are a lot of different arrangements one can come to in these negotiations. Like I said before, it would have to be a jaw dropping amount of money for me to become an employee. I love being independent and I think there are other arrangements we can come to other than employer/employee. I come to the table with a lot more to offer now than I would have even 6 months ago. I have a little bargaining power.

 

[operationivy]

As I wrote in 7/31/08 post.....

"You might make more money on your own, but you also have a lot of headaches. You are going to have to keep track of all the billing and collections on your own. At some point you may be able to hire someone to do it for you but that person could be a complete idiot and cause you even more problems. In addition, your future employees are going to ask for lots of time off, holiday parties, salary raises etc. When you get busy enough to hire even more people, you better boost your productivity even more because you are going to have pay more salaries...."the harder you work, the harder you work." The best thing to do would be to keep your practice relatively small so your office staff #'s/overhead is lower. In a multispecialty group, office staff is already in place and is more streamlined. As I am sure you know, the overhead would be divided multiple times and would be cheaper per physician. Yeah, obviously, the staff could consist of idiots and you have no power to fire them, but if you get a few bad seeds in your solo practice that could be devastating as well. In addition, you are going to have put ads in the paper to try to recruit staff to your office and you will quickly see how poorly qualified most people are. Maybe you will hire one or two and they will fool you into thinking they are good. Then you find out a few months later that they are stealing your money or are so rude on the phone that 20% of your business slipped to another surgery office without you even knowing about it. Or perhaps you get a great employee who you never want to leave and after 2 years they tell you they are moving to California and you better look for someone else....devastating! Money isn't everything and the autonomy you are talking about can certainly be a facade. I would rather make less, have fewer headaches and not be on call all the time so I can enjoy the tailgate party."

Fewer headaches, fewer headaches. In this economy, would go for the salary....it is just a matter of time before there are massive medicare cuts (other insurance companies will follow). The republicans want to cut medicare by over a trillion dollars!! Where do you think that money is going to come from, the patients???? And who can pay out of pocket these when all their money in the market has been cut in half??? I wouldn't want to be a "small business owner" in medicine in the upcoming years.

 

[bananamed]

Fewer headaches, fewer headaches. In this economy, would go for the salary....it is just a matter of time before there are massive medicare cuts (other insurance companies will follow). The republicans want to cut medicare by over a trillion dollars!! Where do you think that money is going to come from, the patients???? And who can pay out of pocket these when all their money in the market has been cut in half??? I wouldn't want to be a "small business owner" in medicine in the upcoming years.

If medicare is being slashed left and right, you think it doesn't affect the salaries of hospital employees?

I'd rather be a small business owner in this economic environment than slaving away for a big institution (filled with all sorts of rules/regulations btw) for a salary that won't climb.

 

[GSresident]

Operationivy:
In this climate, even in a rural state filled with poor people, I was able to build a successful solo private practice. My practice covers an area that is at least 10,000 square miles with at least 500,000 people in it. I am successful enough that a major health system wants to "buy my practice." I did all of this in 3 months. Maybe I just got lucky. I don't know. All I know is, I would rather be in my position with some major chips to bring to the table than be in the position of an employee merely looking for another job.

If I do accept an employer/employee relationship it will be for a jaw dropping amount of money, and by jaw dropping I mean I get a piece of the hospital fees for the cases I bring to the hospital. I think I read in Plastic Surgery News that a hospital's revenue from your cases is conservatively 5 times your billing. I'm telling you, until you have tried it you will never now how amazingly satisfying it is to be the complete and total boss. It would take many big green bags of cash to make up for that feeling.

 

[tri]

Plus, from what i've seen, hospital employed plastic surgeons quickly become overpaid wound nurses. Say good bye to those nice healthy young patients that want a nice quick cosmetic procedure and hello to your old gen surg trauma rotation and lots of wheel chairs and SNF referrals. yippeee. excited yet?

 

[bananamed]

Plus, from what i've seen, hospital employed plastic surgeons quickly become overpaid wound nurses. Say good bye to those nice healthy young patients that want a nice quick cosmetic procedure and hello to your old gen surg trauma rotation and lots of wheel chairs and SNF referrals. yippeee. excited yet?

mmmmm

love that wound care

 

[operationivy]

If medicare is being slashed left and right, you think it doesn't affect the salaries of hospital employees?

I'd rather be a small business owner in this economic environment than slaving away for a big institution (filled with all sorts of rules/regulations btw) for a salary that won't climb.

Good point, but hospitals collect a lot more for procedures/surgeries than a physician in private practice. They get a massive facility fee, which of course may decrease as well with cuts, but there is more of a buffer compared with physicians in private practice. Lets say a private practioner is collecting $500,000 per year and the overhead is 50%. A 10% medicare cut does not come out of the total collections, it comes out of the profits after overhead is paid (obviously your overhead doesn't decrease). So the practioner actually decreases his or her profit from $250,000 to 200,000 (which is more than 10%). I am sure this is not new to any of you guys. In a hospital setting, this doesn't apply because of the massive facility fee, in addition to the physician's fee. Again, cuts will likley trickle down to physicians, but it will not be as acute as in the private practice setting. Another issue in private practice is what will actually happen to overhead in the future. I hate to tell you this, but is is going to go up.... a lot. Our country is in more and more debt (bailout etc...) and this will lead to INFLATION as the government prints more $$....everything will cost more (electricity, cleaning supplies for the patient bathroom etc...). Employess will demand higher salaries to pay for the increased cost of their commute to your office, increasing food prices etc.... Even if insurance rates stay the same for physicians, physicians take home pay and operating costs will be outpaced by inflation. The likelihood is that medicare rates will stay the same or will go down (both presedential candidates want to "cut spending" and surely this will come out of doctor's pockets) and this will be disastrous for the private practioner who is essentially a small business owner. That tax cut for small businesses making less than $250,000 that Obama is talking about will not apply to a plastic surgery office.

I think the bottom line is that physicians need to pool together to proctect themselves from all of this crap. We need to think ahead, anticipate these future issues in advance and not merely react to insurance cuts just when they are about to happen (like a few months ago). We provide an essential service and need to be compensated appropriately for it. We shouldn't have to fight to keep our doors open, we need to focus on the PATIENT. Sad but true.

To the man who started this post and is building his practice, I truly respect you. You are doing an amazing job and you have more sense and guts than anybody I have encountered on this website. I hope you make millions and retire when you are 45!!

 

[GSresident]

OperationIvy:
I am weighing all of the issues you mention with regards to overhead, inflation and the potential of declining reimbursements from medicare/insurance. The arrangement the hospital is most interested in is a set salary for 2 years followed by a production based salary thereafter. The set salary will reflect the value of my practice plus what I can potentially generate during those 2 years.

Here is the problem with a "production based salary" from a hospital. If I collect 1.5 million, the hospital will just say that my overhead was whatever amount they want it to be and pay me a pittance of a salary. I have seen that happen every single time to everyone who has ever been an employee of a hospital. If you are an employee, you have absolutely no control over your overhead and the hospital can inflate the hell out of it and keep your money.

One thing that will be a deal breaker for me is that it will be written in a contract that my overhead will not go above a set dollar amount, and that every penny of that amount has to be accounted for and I get to have my tax attorney review the accounting. I'm simply not going to pay a million a year for 1 day of clinic space a week, a $10 an hour receptionist, a $20 an hour nurse (1 day a week), and a biller. I know exactly how much each element of overhead costs.

 

[dilated]

One thing that will be a deal breaker for me is that it will be written in a contract that my overhead will not go above a set dollar amount, and that every penny of that amount has to be accounted for and I get to have my tax attorney review the accounting. I'm simply not going to pay a million a year for 1 day of clinic space a week, a $10 an hour receptionist, a $20 an hour nurse (1 day a week), and a biller. I know exactly how much each element of overhead costs.

Wouldn't it be a lot easier to have a base + RVU-based production bonus setup or something and ignoring overhead? The overhead appears to be relatively fixed on their part so it doesn't seem like there's much gain for either party in going through all the time and hassle of nickel and diming expenses. Is there a reason it's not done that way? Besides "we want to stick it to you on the overhead".

 

[GSresident]

You can get totally screwed depending on how they figure your overhead. If they arbitrarily set your overhead at a certain % of your collections you can really get rumphumped. Say they set my overhead at 40% of collections and I collect 1.5 million (which is well within the range of probability by the time I would switch to a production based salary) that would mean my overhead for the year was $600,000. Unless that overhead includes a helicopter to and from work they must be smoking crack if they think I will pay that.

The other thing to think about is that your value is not just your RVU based production. Your total value also includes the income you bring to the hospital through operating room fees, hospital room fees etc. Not to mention the value you would bring to the hospital wound care center by having a "plastic surgeon on staff." One hospital has already started marketing itself as the preferred regional wound care center because I'm there. Your value also has to do with how strong your referral base is. If you are in an area that the hospital currently has no market share in, you are bringing new territory to the hospital. It is difficult to calculate the value of all of those things but just realize that you are not powerless when it comes to negotiating salary with a hospital. We'll see how it goes for me. I'm not optimistic that they will want to pay me what the job is worth but we'll see. I meet with the CEO and COO in a couple weeks to set up expectations etc.

 

[docjulian]

Aw, this is really a great thread, keep going.

I used to build websites for customers and luckily ended up studying medicine. If I were you, I would just find some nerdy college student with photoshop and css skills. I don't think that you would have to pay more than 1k$.
And you just ask them to keep it user friendly, so u can edit the contents 24/7.

 

[GSresident]

So I met with the CEO and COO yesterday about relocating part of my practice to their hospital. I was basically told to name my terms. I'm thinking about working there 3 days a week as an employee with (base salary + production) - overhead. So far it sounds like my overhead would only be my own I wouldn't be picking up the tab for other less profitable docs. On the other 2 days a week I would be out in the hinterlands under my own PC with the intention of padding the base and drawing business back to my main hospital. Keeping my PC will have major tax benefits for me. The other benefit of keeping my own name is that the referring docs and populace in the hinterlands know Dr. XXXX Plastic Surgery, not XXXX Hospital Clinic Plastic Surgery.

I've got plenty of time to negotiate, look at contracts etc. Believe me this is nothing I will rush in to. One problem I am having is figuring out how much money I should ask for as my base salary, considering what I am now bringing to the table.

 

[cchoukal]

I'm in a hospital-based specialty so this stuff doesn't really apply to me, but I wanted to add to the kudos and ask you to keep updating this. It really is very interesting.

 

[IsNoGOOD]

Forgive me for my ignorance but if you're pulling in a revenue of 1.5 million with little overhead seeing you did all the hiring work you could get big bucks for your private practice. If you take a 6-7 factor that would mean a management buyout for 10 million, plus you will get salary. With that amount of money you're going to make almost 500.000$ (gross) from interest a year + the (gross) base salary + production - overhead?

 

[GSresident]

This will sound wierd but I think I am getting a post-election boom in my cosmetic business. In the last week I have signed up more cosmetics cases than I did in the previous 4 months.

In other news, I am meeting for dinner tonight with the head of a physician group to talk about me possibly joining the group. We'll see. My negotiations with the hospital are going well. I have another meeting with them on Tuesday.

 

[bjb305]

just some random questions..
how much money did you have to invest in starting a new practice?
and about how many hours a week have you been spending at work to get this up and running?

 

[GSresident]

just some random questions..
how much money did you have to invest in starting a new practice?
and about how many hours a week have you been spending at work to get this up and running?

Hello,
I don't have exact figures yet for startup cost. Believe it or not that is a very complicated question. I will try to answer it when I know the whole amount. As far as hours per week it wasn't that bad. I don't really keep track but I know it is less than 40 on average.

 

[GSresident]

Today was a monumental day in the startup. I got my first check from medicare. That was the first non-cosmetic payment I have gotten since starting practice July 1st. It takes that long unfortunately.

 

[tussy]

Interesting thread! I'm starting a gen surg practice in January and I'm getting stressed out about it just reading your post! I've been working locums since i finished fellowship and enjoy the money without the headaches.

A few issues i'm worried about and would like someone to weigh in on:

1. hiring an assistant - people have already started sending me resumes, and they all look qualified, but i've heard so many nightmares. Any way to weed out the duds? Any questions that I must ask?

2. I'm worried that when I start I'll be getting all the crap cases that nobody else wants; all those high risk, complicated patients. The ones with the high complication rates. I don't want my first cases to be really tough and have all sorts of complications - don't want that reputation in the beginning. The surgeons that are there currently keep telling me about these cases they are "saving for me" and they are all potential disasters!

3. EMR - i'm computer illiterate but think i should probably have an electronic medical record in my office. There are a mind-boggling number of companies out there and choosing one seems impossible (i've asked around the city i'm going and none of the surgeons currently use an EMR, just some GPs and their systems aren't really applicable to a referral based practice).

I've got a month and these are the things on my mind right now. Any advice, experience, comments?

GSresident - keep us updated (and i think you need a new name since you obviously aren't GS and arent' a resident!)

 

[GSresident]

1. hiring an assistant - people have already started sending me resumes, and they all look qualified, but i've heard so many nightmares. Any way to weed out the duds? Any questions that I must ask?

Hold off. There is no need to hire an assistant until an assistant can actually save you money and trouble. When you first start you won't be busy enough to use one and you will be paying for someone to sit around.

2. I'm worried that when I start I'll be getting all the crap cases that nobody else wants; all those high risk, complicated patients. The ones with the high complication rates. I don't want my first cases to be really tough and have all sorts of complications - don't want that reputation in the beginning. The surgeons that are there currently keep telling me about these cases they are "saving for me" and they are all potential disasters!

This is true if you are moving to an area with other established surgeons. If I were you I would pick an area where you are known, have family etc. The other option would be to move out to the middle of nowhere where a surgeon is actually needed. I see a lot of your practice coming from ER referrals. That sucks.

3. EMR - i'm computer illiterate but think i should probably have an electronic medical record in my office. There are a mind-boggling number of companies out there and choosing one seems impossible (i've asked around the city i'm going and none of the surgeons currently use an EMR, just some GPs and their systems aren't really applicable to a referral based practice).

Again I would hold off. If no one else is using it maybe there is a reason. I am using paper charts myself right now and I will continue to do so until an EMR will save me time and money.

Everything that you spend money on for your practice needs to be something that is going to improve your productivity and make your life better. Best of luck.

The thing I would do right now if I were you is get all signed up for insurances. That is a ton of work and takes a lot of time.

 

[GSresident]

A few more developments in the last month.

I started getting paid in a trickle. The trickle is enough for me to start paying down my credit card. Its pretty unbelievable that a company or companies can owe me so much money and decide they are going to drag out paying the bill. My accounts receivable over 60 days old is a staggering number, at least to me. The biggest tactic I see both from private companies and from medicare is to just say 'oh we never got that bill,' even though I have electronic proof that they got it and when they got it. Another big trick is to just blanket deny everything and hope that I just ignore it. I appeal EVERY denial. My documentation is impeccable so I almost always win.

I am scouting out a new satellite on Thursday. This one should be very lucrative after I get a patient base established.

I was involved in a big bruhaha between the ENT docs and the ER. One of the ENT docs at one of the hospitals I work at was trying to force me into a week of call a month at said hospital. Since I only spend 4 days a month there it wasn't going to happen. I went to a meeting and successfully fended off that effort. The guy went ballistic and started attacking everyone at the meeting so I doubt very seriously if he will ever be able to conscript me. Something positive did come out of the meeting - I was asked to draw up guidelines for when it is appropriate to consult a specialist for facial laceration closure. This particular ER is famous for calling consults for 0.25 cm lacerations on the foreheads of 95 year old men. I used the guidelines in the main Pediatric Emergency Medicine textbook and added a few additional guidelines. It should make face call there a little better for the ENT docs.

I gave a big speech at a CME meeting for primary care docs. It was shock and awe. I also was recruited to start playing in a band. I've been a drummer since I was 3 and I picked up a guitar in 2001. Its been a lot of fun and a nice distraction. Other than that, not a whole lot new.

 

[maxheadroom]

Are you getting a lot of nuisance/BS ER consults? How are you dealing with them?

 

[Winged Scapula]

A few more developments in the last month.

I started getting paid in a trickle. The trickle is enough for me to start paying down my credit card. Its pretty unbelievable that a company or companies can owe me so much money and decide they are going to drag out paying the bill. My accounts receivable over 60 days old is a staggering number, at least to me.

I have a little palpitation everytime I see that AR column as well...the amount of money is frustratingly high especially in that 60-90 day period.

The biggest tactic I see both from private companies and from medicare is to just say 'oh we never got that bill,' even though I have electronic proof that they got it and when they got it. Another big trick is to just blanket deny everything and hope that I just ignore it. I appeal EVERY denial. My documentation is impeccable so I almost always win.

Glad to see you being proactive about this. Many physicians, especially surgeons are not. They just assume they get paid what they are supposed to without ever realizing that insurance companies routinely deny stuff without real cause or just never pay, claiming they "lost" the bill. My billing company isn't that great either so I have to watch what they are doing because if I don't, they'll just write stuff off rather than appeal. Two months ago my collections were *really* low - like low enough to barely cover my expenses, they couldn't figure out why, nor could I, except the AR column. Well last month? Collected 5 times the amount (if only that could stay static then I would comfortable this November going off my guaranteed salary) of the month previously when I said, "something is wrong, fix it" because I'm billing a hella lot more than we're getting (not withstanding the usual being paid less than the you bill for).

 

[GSresident]

Are you getting a lot of nuisance/BS ER consults? How are you dealing with them?

I have been dealing with the BS ER consults by prevention. I'm not on the call schedule unless I specifically sign up for a certain day, which I will occasionally do to help one of the ENT docs out. There was a bit of a bruhaha about this but I think I have effectively nipped it in the bud (see above post).

 

[GSresident]

I have a little palpitation everytime I see that AR column as well...the amount of money is frustratingly high especially in that 60-90 day period.



Glad to see you being proactive about this. Many physicians, especially surgeons are not. They just assume they get paid what they are supposed to without ever realizing that insurance companies routinely deny stuff without real cause or just never pay, claiming they "lost" the bill. My billing company isn't that great either so I have to watch what they are doing because if I don't, they'll just write stuff off rather than appeal. Two months ago my collections were *really* low - like low enough to barely cover my expenses, they couldn't figure out why, nor could I, except the AR column. Well last month? Collected 5 times the amount (if only that could stay static then I would comfortable this November going off my guaranteed salary) of the month previously when I said, "something is wrong, fix it" because I'm billing a hella lot more than we're getting (not withstanding the usual being paid less than the you bill for).

The best thing you can do to retire early is make sure that you get paid the money you are owed. It takes effort on your part to make sure you aren't being ripped off. My dad could have retired >10 years ago if he was as aggressive with his billing as I am.

 

[Habeed]

What I enjoy reading about this thread is how GSresident has seriously grown some balls. I might be wrong, but I suspect he was forced to be very deferential and flat out suck up to his attendings all throughout medical school and residency.

Now that no one is holding the threat of firing him or giving him a bad grade over his head, he has a chance to actually stand up for himself.

 

[JaggerPlate]

I suspect he was forced to be very deferential and flat out suck up to his attendings all throughout medical school and residency.

That's quite an assumption. He may have just worked hard, been personable/respectable and ... well, 'good.'

 

[Habeed]

That's quite an assumption. He may have just worked hard, been personable/respectable and ... well, 'good.'

Given how determined he is now to make his new status work, I think he did everything he could during his residency/fellowship to make it. If you have to suck up and pipe down, you do it.

 

[JanetteBournes]

What I enjoy reading about this thread is how GSresident has seriously grown some balls. I might be wrong, but I suspect he was forced to be very deferential and flat out suck up to his attendings all throughout medical school and residency.

Now that no one is holding the threat of firing him or giving him a bad grade over his head, he has a chance to actually stand up for himself.

You make a lot of assumptions for someone who isn't in medical school yet..

 

[maxheadroom]

Fact is, in Plastics you have to be deferential to others. If you want physicians to refer you patients, you have to be nice. You have to see their patients promptly, make the patient happy, and make the referring doc feel good about the care that you have his patient.

 

[Winged Scapula]

Hell, in any sort of private practice, PRS or not, you have to be deferential when you count on referrals.

 

[Chuck's Right Foot]

Hell, in any sort of private practice, PRS or not, you have to be deferential when you count on referrals.

Is it be deferential? or just having good people skills when you... you know.... have to deal with people ??? 🙂

 

[Winged Scapula]

Is it be deferential? or just having good people skills when you... you know.... have to deal with people ??? 🙂

Probably a little of both.

 

[GSresident]

I have successfully negotiated my expansion into the biggest market in the state and I am beginning the transition now. I am keeping all of my current practice and starting the new market as a satellite, to be expanded to the primary location once it gets busy enough. The sticking point was that I didn't want to take any ER call for their crappy trauma center. I was insistent on that point and I was successful. I will not be taking an hour of ER call ever.

I am supposed to give a grand rounds in May at my old residency program on how to start a practice. One of the things that I am going to suggest to people is that you are valuable and everything is open to negotiation. I've seen some of the bills my patients have gotten from the hospitals. On average, the hospitals are billing, and collecting, 10 times what I bill and collect, so that even a simple skin lesion removal very quickly gets into the $5-6000 range for the hospital. My bigger surgeries generate many many times that for the hospital. You are a valuable commodity as a surgeon. If you are reasonable and nice about things, the hospitals will likely negotiate with you.

 

[tussy]

I'm 6 weeks in and doing much better than i thought.

I hired a secretary fresh out of secretary school so I can pay her less and break her in! I am sharing office space with an established surgeon so i didn't have to invest too much in office equipment and supplies and bought some equipment from a doc who was retiring.

Once the GPs learned I was in town the consults started trickling in. I saw them all promptly, especially the crappy ones and now suddenly they are pouring in. I have slowed down the office because I've filled my OR slate for the next 2 months and am looking for extra OR time to accomadate all the new cancers that I'm picking up doing screening colonoscopies (5 last week alone).

I'm signed on for an EMR, bought computers, and am setting up a network in my office, etc and hope to have it up and running by early March.

I have successfully paid off my startup costs with my billings so far (the joy of a single payer system in Canada - yeah canada), although I haven't paid my taxes for last year yet and that will be a big bill.

Meeting with my accountant to incorporate myself (major tax shelter - ie only pay corporate tax rather than personal income tax) and see when i can afford the house I want so i can get out of this crappy apartment ASAP.

 

[droliver]

If you are reasonable and nice about things, the hospitals will likely negotiate with you.

True to a point. However, Plastics is not valued as much as most other surgical specialties. We generate much less $ per time then ortho, optho, podioatry, neuro, general, CTVS, Urology, etc... and unless you're a hand surgeon doing 6-10 cases/day, you're not likely to be bringing the volume to have much leverage. Our cases just take too long. This is even more true in the outpatient ASC setting. We're the least desirable specialty for an ASC profit wise I'm told.

They will throw you overboard in a second if they need your OR time, resources, etc.. to recruit other business. I've watched this play out sequentially in the cities I've trained and now practice in. Cosmetic surgery is usually the 1st target as it's a loss leader in most instances on facility fees (Anesthesia loves it however).

 

[Mariah246]

True to a point. However, Plastics is not valued as much as most other surgical specialties. We generate much less $ per time then ortho, optho, podioatry, neuro, general, CTVS, Urology, etc... and unless you're a hand surgeon doing 6-10 cases/day, you're not likely to be bringing the volume to have much leverage. Our cases just take too long. This is even more true in the outpatient ASC setting. We're the least desirable specialty for an ASC profit wise I'm told.

They will throw you overboard in a second if they need your OR time, resources, etc.. to recruit other business. I've watched this play out sequentially in the cities I've trained and now practice in. Cosmetic surgery is usually the 1st target as it's a loss leader in most instances on facility fees (Anesthesia loves it however).

Really? I would have figured the cosmetic cases move at a quicker pace? I should add I know next to nothing about plastics and this was just my conjecture.

 

[core0]

True to a point. However, Plastics is not valued as much as most other surgical specialties. We generate much less $ per time then ortho, optho, podioatry, neuro, general, CTVS, Urology, etc... and unless you're a hand surgeon doing 6-10 cases/day, you're not likely to be bringing the volume to have much leverage. Our cases just take too long. This is even more true in the outpatient ASC setting. We're the least desirable specialty for an ASC profit wise I'm told.

They will throw you overboard in a second if they need your OR time, resources, etc.. to recruit other business. I've watched this play out sequentially in the cities I've trained and now practice in. Cosmetic surgery is usually the 1st target as it's a loss leader in most instances on facility fees (Anesthesia loves it however).

I've heard different. Hospitals love cosmetic plastics since those are for the most part cash on the barrel head. No problems with insurance companies etc. Not counting hand other plastics should have a better payor mix than most general surgery cases. Also pretty easy for the hospital to deny a plastics case to a self/no pay unlike other surgeries.

The reasons that most plastic surgeons have their own ASC is to gather up that facility fee also from cash paying patients. They are the only ones that make it cost effective to run a single surgeon ASC.

David Carpenter, PA-C

 

[dilated]

I've heard different. Hospitals love cosmetic plastics since those are for the most part cash on the barrel head.

The question in my mind is whether aesthetics is actually worth it. The sucking up to patients, having to get a fancy office, taking ED call, sweating results and all the other hassles that go with it might outweigh getting paid crap for a 10 hour free flap. But if the salary figures I've seen over and over are accurate, all that effort to get aesthetic patients ends up getting you paid the same as the urologist who puts minimal effort in and bangs out cystos all day. The only benefit to doing aesthetics seems to be if you're one of the 30 guys in the country who books completely with high fee cosmetics.

I think PRS is quite cool but the future as an attending actually seems worse than other surgical subspecialties.

 

[maxheadroom]

I've heard different. Hospitals love cosmetic plastics since those are for the most part cash on the barrel head. No problems with insurance companies etc. Not counting hand other plastics should have a better payor mix than most general surgery cases. Also pretty easy for the hospital to deny a plastics case to a self/no pay unlike other surgeries.

The reasons that most plastic surgeons have their own ASC is to gather up that facility fee also from cash paying patients. They are the only ones that make it cost effective to run a single surgeon ASC.

David Carpenter, PA-C

Most of my friends have found hospitals to be less-than-interested in aesthetic cases, mostly because the surgeons are always trying to negotiate down the hospital/anesthesia fees. Hospitals charge waaaaaay too much for most cosmetic procedures. A well-run ASC can contain costs better, but plastics cases don't make much money for hospitals and therefore they aren't too willing to negotiate fees that patients are able to pay.

Most Plastic surgeons build/buy into an ASC for a couple of reasons. First, they can make some money off of the OR fees. Second (and more important), they can manage the ASC in a way that is more conducive to their practices.

 

[DOCTORSAIB]

Really? I would have figured the cosmetic cases move at a quicker pace? I should add I know next to nothing about plastics and this was just my conjecture.

Have you ever scrubbed in with a high-volume ophthalmologist? They bang out those cataracts like there's no tomorrow...

I'm thoroughly enjoying this thread. OP, big props for teaching us newbies the ropes of PP! 👍

 

[droliver]

I've heard different. Hospitals love cosmetic plastics since those are for the most part cash on the barrel head. No problems with insurance companies etc. Not counting hand other plastics should have a better payor mix than most general surgery cases. Also pretty easy for the hospital to deny a plastics case to a self/no pay unlike other surgeries.

The reasons that most plastic surgeons have their own ASC is to gather up that facility fee also from cash paying patients. They are the only ones that make it cost effective to run a single surgeon ASC.

Then you've heard wrong. Hospitals make MUCH, MUCH more in facility fees from insurers then they do on cosmetic cases.

Look at a patient's bill sometimes. For instance, the cash fee for a breast augmentation which may tie up a room and staff for 90-120 minutes (including transport, prep time, surgery time, transport, turnover) may command $1000-1500 facility fee, versus $5000-9000 for an arthroscopy on a patient with insurance or medicare.

The "facility fee" for cosmetics one would charge in an office ASC is a loss leader for the convenience in scheduling and setting. When standard accounting practices reviews these OR's expenses (not the way a layperson would) they are almost universally money losers according to practice management consultants. They may offer the MD convenience and some hedge against hospitals fee changes, but they do not make money.

It would be simple enough to say "Why don't I just bill insurance as an out of network ASC?" and get the facility fee for that on cases like breast reductions, septoplasties, etc... that can be done as an outpatient in selected patients. By in large, insurers and medicare do not play ball out of deference to the hospital lobby and any state regulations which may apply to oversite. When you can successfully negotiate this, many people could potentially drawrf their collections from procedural fees thru facility charges.

 

[droliver]

Have you ever scrubbed in with a high-volume ophthalmologist? They bang out those cataracts like there's no tomorrow

Cataract business is much less profitable for the hospital then retina surgery on a per case basis (this according to my hospital CEO whom I was discussing this about a week ago)