How to get - or not get - referrals

[Feli]

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I don't see pts on Fridays, but ER messaged me while I was at lunch to tell me they are sending me a bimall equivalent (ok).

They've been sending most/all ankle fractures to ortho the hospital hired last year.
I got most/all ankle injuries prior to that, but I have plenty of other stuff to do and this isn't a scope/turf thing.
So, the report on this one said "...Minimally displaced distal fibular fracture at the level of the syndesmosis. The medial clear space measures 4 mm, which is at the upper limits of normal and raises suspicion for ligamentous injury." They splinted and sent it to me for f/u next week.

I stopped by the ER omw back from lunch to say thanks. Then, I saw it... they have a full page list with every major joint and what the ortho will / won't take. It also clearly spells out not to contact that doc on weekends. It's crazy. It's stuff like this (actual list is waaay longer)...

RADIUS: fracture - yes, compound fracture - no
HUMERUS: fracture - yes, compound fracture - no, dislocation - no
SPINE: no
HIP: fracture - no, dislocation - no, bursitis - yes
KNEE: septic - no, ligaments - yes, fracture - no
ANKLE: fracture - yes, ligaments - no
FOOT: no

So basically, I got sent this refer since it was unclear if fracture or ligaments... and probably also because it was a weekend. Lol. They were directed by the hospital (and a bit by me) to send to the ortho to get them busy, but they were honestly confused on this as to if ortho wanted it.

...For MD/DO specialists, they can obviously pick what they want (especially if hospital employed, mostly salary). They're not saturated. They're hard to recruit. This one is making it tough to send with the specifics, though. They have that luxury.

For us podiatrists (PP or hospital), it's crazy not to take everything. At least for awhile... but probably forever in nearly any area (just expand department / offices if overflow). We are pretty limited scope to begin with, so it seems natural to get trained for all you can... and to do it all after. There are definitely some things I encourage (sports, derm, tendon, fractures, etc) and some I don't (wounds, nail care RFC), but I see some of everything. There are tons of us in nearly any area, and you can lose some refers fast to ortho or podiatry who comes in - sometimes even to midlevels.

Personally, I always just say "we can take care of anything below the knee." It makes it easy for PCPs, ER, whoever to send to me. I want it to be easy to remember. Sure, there is the odd thing manifesting as foot/ankle that I can't treat (neuropathy from back pain, PAD, rheum inflammation systemic, big recon I don't want at smallish hospital), that's usually less than 1% of my refers... and I just refer it appropriately.

...What do other people usually tell MD/DO refers as to what we can treat? How do you make it easy to refer to you?
It's a marketing thing, but also just good communication. I thought this was a pretty extreme example of how to make it hard to sent to the ortho (they will get full anyways, but not as fast as they could).

It goes without saying that MD/DO expectation and perception of podiatry is all over the board due to varied training types/quality.
I think it's important to get a handle on this in local hospitals and area to get maximum podiatry refers. It's dog-eat-dog in many places.

 

[deleted1235332]

I’m always skeptical if something was going to be referred to ortho but somehow ends up to me. There’s always a reason.

 

[Feli]

I’m always skeptical if something was going to be referred to ortho but somehow ends up to me. There’s always a reason.

They're MDs, man... some will be cool to us, but they'll always prefer one another if possible. That won't change.
Ortho will get the 25F normal BMI ankle fracture from basketball BCBS... podiatry gets the 61M diabetic BMI 42 for Jones fracture MedicAid.

And hospital employed/contractor docs (PCP, ER, or any specialty) will always do whatever admins tell them to do... get the new ortho/onco/endo/whatever busy, order more XYZ, send wounds to the hospital DPM, send to PT, etc etc.

MSG docs will obviously keep everything they can in their group, labs, maybe surgery center, etc. They're a bit of a dead end unless no DPMs.

Other PP docs/groups (family, int, peds, rheum, derm, whatever) are actually free will and our best bets... will tend to send to who sends to them, who gets good results, who patients give good feedback on, who markets and gifts them. 🍪

...It's mainly about saying what will make it easy to refer to you, though. That "anything below the knee" is the best I've found (note it's not "from the knee down." I always thought those podiatrists who try to be wound wizard or Mr. Big Recon or C&C only are limiting an already limited and competitive game. It's easier for PCPs to have a doc who is likeable and they can just send everything F&A to.

I was hoping to hear some more scripts, ideas... the stuff we tell docs in the lounge, hallway, at meetings to drum up and retain refer sources.

 

[Bluecollarmed]

Our group has a list of things we do and don't treat that circulates to the EDs/UCs. My ortho partners don't do hand or wrist and we collectively don't really operate on kids except for certain things because there's a children's hospital down the road. I'll refuse certain higher acuity things or things that need workup we don't have immediate access to (infections with PAD due to no ABI/art US or vascular at the facility). We have the leeway to say yes and no to consults which is nice. I routinely get VLU wound consults that would require multiple visits per week for wraps and it just bogs down clinic due to low staffing at the rural hospital so those get punted to area wound centers. I'll take some DFUs that are surgical because it's providing a service that the wound center PA/NP/Nurses can't do so these patient's aren't just stuck in weekly visits til they die. Luckily for me patients like me and so do the PCPs/ED docs which keeps refers coming. It also doesn't hurt that new patient visits at the larger facilities in the area are 4-6+ months for podiatry from what some patients have told me.

My call is also "available" meaning I'll pick up the phone but if it's a weekend or a holiday I'm probably not coming in.

 

[Hybrocure]

In PP I have had nothing but headaches getting paid for ER consults/inpatient work especially depending on the insurances, or lack thereof. I try to avoid it as much as possible unless it’s a personal patient from my own clinic who ends up at the hospital.

 

[eyeeye_captain]

In PP I have had nothing but headaches getting paid for ER consults/inpatient work especially depending on the insurances, or lack thereof. I try to avoid it as much as possible unless it’s a personal patient from my own clinic who ends up at the hospital.

As an update to my thoughts on unpaid call, I got ANOTHER hospital, with whom I have no affiliation or credentials, who DOES have eye docs in their system (including one of my competing practices), tried to call me about a patient we’ve never seen. “Hey call service, tell them goodbye and to never call again.”

Agree that getting paid and often just the logistics are way too painful to make it make sense. Agree that I’ll answer if it’s one of ours.

Maximizing ED consults to build a practice strongly risks filling your time without filling your wallet.

 

[DYK343]

Hospital made a rule where PCPs have to refer within the hospital system if the specialty is there.

They really cant enforce it but they track it and if a PCP is referring out they will be approached and "educated on the services within the hospital".

I feel bad for my DPM PP friends in the area but it took much of their business.

 

[footpainhealer]

Hospital made a rule where PCPs have to refer within the hospital system if the specialty is there.

They really cant enforce it but they track it and if a PCP is referring out they will be approached and "educated on the services within the hospital".

I feel bad for my DPM PP friends in the area but it took much of their business.

Yikes. Reading things like this really makes it tough to gauge whether it's worth it or not to start a new solo private practice.

Several of the solo/small groups around where I grew up and went to school seem to be part of some group now, not necessarily private equity groups. Can't figure out why though cause AFAIK, they were doing quite well when I was around those areas 5-10 years ago.

This weekend, I looked up one of the jobs I was considering in a small metro area of a southern state last year, just to see who they hired....
It's someone that's >65 years old, and I looked him up...... he owned his own practice, including the building and surgery center that was within the building, prior to joining this MSG. From what I can gather from the old website, the practice was a family members and he took it over and ran it for 30+ years.

Things like that make me "pucker" because I would expect someone that owned their own practice/building/ASC for over 30 years (who also may have been just handed the practice down from a family member without any upfront cost) should be retired and enjoying life, not joining a crappy MSG that's ran by a bunch of NP's.

Maybe I am overthinking it, but those are just a couple of the examples that give me pause on pursuing a solo practice in this climate.

 

[heybrother]

Yikes. Reading things like this really makes it tough to gauge whether it's worth it or not to start a new solo private practice.

Several of the solo/small groups around where I grew up and went to school seem to be part of some group now, not necessarily private equity groups. Can't figure out why though cause AFAIK, they were doing quite well when I was around those areas 5-10 years ago.

This weekend, I looked up one of the jobs I was considering in a small metro area of a southern state last year, just to see who they hired....
It's someone that's >65 years old, and I looked him up...... he owned his own practice, including the building and surgery center that was within the building, prior to joining this MSG. From what I can gather from the old website, the practice was a family members and he took it over and ran it for 30+ years.

Things like that make me "pucker" because I would expect someone that owned their own practice/building/ASC for over 30 years (who also may have been just handed the practice down from a family member without any upfront cost) should be retired and enjoying life, not joining a crappy MSG that's ran by a bunch of NP's.

Maybe I am overthinking it, but those are just a couple of the examples that give me pause on pursuing a solo practice in this climate.

1. I just left a practice where my partner was maybe bringing in $300K in total collections. Yes, he is ABFAS certified and I assure you - he didn't fill out their survey. But you can be practicing 25 or 30 years out for many a reason - from poor business decisions, to can't quit, to didn't save, to divorce to whatever. Yeah you should be retired at 30 years, but the reasons people are still practicing are infinite.

2. If you don't start your own practice - then what are your options? You face all the negative repercussions if you are private practice employed but with 30% of collections instead of a chance of controlling the business and profits. Consider my new practice - precarious - of course. But my partner was charging us $5000 in rent (fraudulently). Now that I own my own building the rent is just my other pocket. We paid Athena $72K last year. Now I'm ECW paying ..$600 a month + some version of Healow or whatever I switch to for credit card charges. And I left my partner with his overpriced IT partner and took it on myself. Tens of thousands saved. Turns out I was personally capable of setting up the clinics email, setting up a fax machine to email/receive faxes->convert to an email, and setting up employee accounts on computers. I'm paying a payroll company but I'll drop them eventually and save a few hundred. My partner wanted us to pay someone like $1400 a month to do book keeping. I'm not enjoying it but I'm getting better at it every week. I now know enough to teach my wife.

3. I won't deny the power of referrals but I will tell you that a lot of insurances that require referrals are garbage. BCBS PPO, Cigna and Medicare don't require referrals. Yeah - its tough now. Companies are ditching their good insurance. Medicare is losing patients to BS medicare advantage plans - but the kind of insurances that actually pay the bills don't technically require a referral.

 

[Feli]

Hospital made a rule where PCPs have to refer within the hospital system if the specialty is there...

Yeah, that is basically unspoken rule for any hospital or MSG that I have ever seen, worked for, interviewed with. They usually can't out and out say or publish it as that goes against good medical decision making... but there is absolutely the expectation that refers will stay in the bubble.

For any employed DPMs, I think if you were to send even 10% of your PT, MRIs, vasc refers, DME, orthotics, etc outside your hospital / MSG / supergroup who owns+operates that same service, you would be onto thin ice very fast. You obviously don't operate anywhere else if they own ORs or ASC.

I will market a bit and try to have a good relationship with hospital-employed PCPs (and other specialists), but I know very well that I could lose most/all of those refers any minute if their hospital hires a pod/ortho. They all know who signs their paychecks. I also find the hospital docs are generally harder to access... on the phone, stop by, etc. The independent docs and groups who don't have a podiatrist are always my best bet for consistent refers as a PP.

In PP I have had nothing but headaches getting paid for ER consults/inpatient work especially depending on the insurances, or lack thereof. I try to avoid it as much as possible unless it’s a personal patient from my own clinic who ends up at the hospital.

...Agree that getting paid and often just the logistics are way too painful to make it make sense. Agree that I’ll answer if it’s one of ours.

Maximizing ED consults to build a practice strongly risks filling your time without filling your wallet.

Agree totally... ER (and Urgent Care, and consult inpt) refers for f/u are just a way to build early on (or after adding associate?). I want to take on as few as possible of those once full and on a waitlist. I'd prefer they go to hospital DPMs or other newer PP pods. I want the vast majority being PCP refers with good insurance.
We've had pretty good luck doing work comp (only because our biller svc is awesome), but it's nowhere near quality of PCP refer new pts. In a smallish town, it will all have to be done to at least a small degree, though. Hopefully mostly only PKTY from ER. 🙂

Yikes. Reading things like this really makes it tough to gauge whether it's worth it or not to start a new solo private practice. ...

There are a lot of advantages to owning an office that aren't financial. Namely, you own yourself. (both psychologically... and tax deductions)
You stop being a grown man with a "boss," don't have to ask HR for vacation days approved, you are not trying to get "data" to make your case for a raise every year or two, no more hoping the staff and marketing you get are good and will stay awhile, you aren't at the mercy of those owners/admins (which may very well change during your employ) who make or break your job quality. All of that goes away... but you obviously have to make the biz decisions for the office - or hire someone competent to do so.

I would say work for a couple years, then make the decision. Different people like different roads; they value different things. Owner/partner is not the magic road to riches it once was, but it's still definitely not bad (depends largely on area insurances/saturation). Similarly, some employed jobs are not bad either (depends almost entirely on admins).

The main problem with podiatry PP (or most specialties) is just that costs go up while reimburse (MCR... and all insurances set off MCR) are pretty stagnant for decades now. An ingrown procedure or a heel inject today 2026 pays basically what they did in 1990 or 2000... but the rent, medical assistant, EMR, student loan, etc etc are at least 2-3x the cost they were back then. Tuition has skyrocketed also. There is only so much meat on the bone.
That is why the scammy services exist, why "new codes" pop up... why fraud exists. That is what the private equity supergroups do: buy normal PPs (or start new locations), and then they lower pay of docs and/or add new "ancillary services" (95% scammy ones) and "protocols" to lead to those services. There is only so much meat on the bone... and 99% of patients only need the basics... and that only pays so much.

 

[Feli]

I’m always skeptical if something was going to be referred to ortho but somehow ends up to me. There’s always a reason.

This applies for podiatry as a career in general:

If there is 'med school' that doesn't require getting into med school, and then you will treat pathology MDs are happy to give up... there is a reason for that. 🙂

 

[air bud]

This applies for podiatry as a career in general:

If there is 'med school' that doesn't require getting into med school, and then you will treat pathology MDs are happy to give up... there is a reason for that. 🙂

100% of the time if there's some type of trauma there's a reason why it's in your office. Unless you're a reconstructive foot and ankle surgeon who is fellowship trained...

 

[Sybly]

Yeah, that is basically unspoken rule for any hospital or MSG that I have ever seen, worked for, interviewed with. They usually can't out and out say or publish it as that goes against good medical decision making... but there is absolutely the expectation that refers will stay in the bubble.

For any employed DPMs, I think if you were to send even 10% of your PT, MRIs, vasc refers, DME, orthotics, etc outside your hospital / MSG / supergroup who owns+operates that same service, you would be onto thin ice very fast. You obviously don't operate anywhere else if they own ORs or ASC.

I will market a bit and try to have a good relationship with hospital-employed PCPs (and other specialists), but I know very well that I could lose most/all of those refers any minute if their hospital hires a pod/ortho. They all know who signs their paychecks. I also find the hospital docs are generally harder to access... on the phone, stop by, etc. The independent docs and groups who don't have a podiatrist are always my best bet for consistent refers as a PP.



Agree totally... ER (and Urgent Care, and consult inpt) refers for f/u are just a way to build early on (or after adding associate?). I want to take on as few as possible of those once full and on a waitlist. I'd prefer they go to hospital DPMs or other newer PP pods. I want the vast majority being PCP refers with good insurance.
We've had pretty good luck doing work comp (only because our biller svc is awesome), but it's nowhere near quality of PCP refer new pts. In a smallish town, it will all have to be done to at least a small degree, though. Hopefully mostly only PKTY from ER. 🙂


There are a lot of advantages to owning an office that aren't financial. Namely, you own yourself. (both psychologically... and tax deductions)
You stop being a grown man with a "boss," don't have to ask HR for vacation days approved, you are not trying to get "data" to make your case for a raise every year or two, no more hoping the staff and marketing you get are good and will stay awhile, you aren't at the mercy of those owners/admins (which may very well change during your employ) who make or break your job quality. All of that goes away... but you obviously have to make the biz decisions for the office - or hire someone competent to do so.

I would say work for a couple years, then make the decision. Different people like different roads; they value different things. Owner/partner is not the magic road to riches it once was, but it's still definitely not bad (depends largely on area insurances/saturation). Similarly, some employed jobs are not bad either (depends almost entirely on admins).

The main problem with podiatry PP (or most specialties) is just that costs go up while reimburse (MCR... and all insurances set off MCR) are pretty stagnant for decades now. An ingrown procedure or a heel inject today 2026 pays basically what they did in 1990 or 2000... but the rent, medical assistant, EMR, student loan, etc etc are at least 2-3x the cost they were back then. Tuition has skyrocketed also. There is only so much meat on the bone.
That is why the scammy services exist, why "new codes" pop up... why fraud exists. That is what the private equity supergroups do: buy normal PPs (or start new locations), and then they lower pay of docs and/or add new "ancillary services" (95% scammy ones) and "protocols" to lead to those services. There is only so much meat on the bone... and 99% of patients only need the basics... and that only pays so much.

Yes so true