My experience buying out a retiring podiatrist straight out of residency

[PeaJay]

I agree with your billing in the given scenario.

-First visit: E&M plus procedure.
-Second visit: in given scenario I usually bill just procedure. Should the patient need options explained in detail the with tons of questions I bill an E&M. My billers claim that Evaluation for a minor procedure justifies an E&M code.

I usually just do pain and onychocryptosis for diagnosis. Possible cellulitis etc if justified by exam.

Edit: I have a billing department that handles the billing and any subsequent denials. I get suggestions/corrections based on prior rejections, but ultimately am less involved with billing compared to the private practice cohort.

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[king22]

Not really, no. If you should get paid for something, and you don't, fight it. If you are audited and fail because of something you disagree with, fight it. Coding is not that difficult, AND if your medical record justifies the reason for the level of coding you submit, and you don't get paid, fight it. It's not rocket science, but don't think that insurances are in the business of paying you, either. They are in the business of paying you as little as they can get away with. It's up to you to fight for what you think you should get paid. According to the fee schedule of course. And as long as you know the ropes. If you fight for unbundling, good luck with that. Fight for what you believe to be fair and yours. As I've said, I've been audited, and if you are just going to lie down for them, you deserve what you get.

100% agree. If it's legit- Fight Fight Fight!. I have this argument with one of my employers all the time. He routinely "writes off" unfair denials because "it's not worth the hassle". To me, this is extremely short-sighted decision making. When you write these things off, all it does is encourage the insurer to do deny your claims more often. Sadly, this "write it off" mind-set i've found to be quite common in our profession.

 

[NobodyDPM]

You answered my question above with “there is always pain attached.” So let’s try this again.

healthy 20 yo comes in 4 months after left hallux matrixectomy. Complains of “the same problem starting on my right big toe.” Has tenderness to palpation of the right hallux later border. Some swelling but no gross erythema or drainage. He wants “the same thing you did on my other toe” and you agree. You do a matrixectomy on the lateral border of the right hallux.

That’s the scenario I described above that several folks say they will bill an e/m on. Nothing wrong with that. But how are people who are billing the e/m in a situation like that coding it?

99213 - 25 with what dx?
11750 - T5 with I’m assuming L60.0?

I see this somewhat regularly. On the new patient I will bill the e/m and the matrixectomy with the same dx when there is no infection. If that same patient comes in a few months later and I do nothing other than walk in the room, look at the toe and go “yup, let’s do the other side,” (again, absent any other dx including infection) then I personally just bill the procedure code. Like I said, this is a common scenario that I’m curious know how people are billing and how they are justifying. Might just change the way I bill. But I will say the people who refuse to answer the question are likely doing so because they know what they are doing is questionable and they don’t want to broadcast it…

Why wouldn't you bill an E/M for this?

And it is a different code. It's a different toe.

If you have a patient who comes in with an ulcer, it heals, and then the same ulcer shows up on the other foot, you aren't billing an E/M code for evaluating the wound?

You can say this about anything we do. Someone comes in with heel pain. Gets better with a shot. They come in asking for a shot for the other heel. No E/M billed?

 

[dtrack22]

And it is a different code. It's a different toe.

It’s starting to make sense why you’ve been audited several times. Why can’t you answer the question?

 

[dtrack22]

If you have a patient who comes in with an ulcer, it heals, and then the same ulcer shows up on the other foot, you aren't billing an E/M code for evaluating the wound?

Im more than likely billing an e/m but it’s not for “evaluating the wound” itself. That’s right out of the NCCI manual example I posted earlier. Your debridement code covers evaluation of the wound itself just like the lac repair code covers the decision to suture up the lac made by the ED doc. In the case of the ED doc the evaluation for any additional neurologic injury from the accident that led to the lac is what you get paid on the e/m for. So in the case of the new wound on the opposite foot my e/m is for the evaluation of the associated equinus, flexion contracture, acquired foot deformity, hammertoe, etc.

The wound scenario is apples and oranges to walking in the room of a young healthy person that requires nothing more than walking in the room and saying, “yeah you need a matrixectomy again,” where there is no other pathology is present and there is zero additional workup is required because you already did that months ago.

so yeah, the wound probably looks something like

99213 - 25 M24.571
11042 L97.512/E11.621

I see 15-20 patients in clinic 3 days per week and have a morning of surgery. With that I end up doing shy of 600wRVu per month. That’s around 75th percentile of MGMA production. So I’m plenty aggressive with how I bill. Apparently just not aggressive enough since I don’t put e/m codes and 25 modifiers on every single visit…

 

[NobodyDPM]

@dtrack22 instead of taking a stab at me, and also telling me all your RVUs, which I couldn't care less about, let's just agree to disagree and move on. You aren't interested in a discussion about this. You want to be right. Good for you.

You bill your way, and I'll bill mine. Your billing habits don't effect me at all.

 

[619]

99213 - 25 with what dx?
11750 - T5 with I’m assuming L60.0?

For me, I always add the pain code. so it will be 99213 - 25 with M79.67x and 11750 - T5 with L60.0

Even if the patient came in and said they have an ingrown nail, YOU the doctor makes the diagnoses for the ingrown nail and not the patient. Same way patient comes in for a bunion, hammertoe or whatever obvious pathology.

Without pain, they won't be sitting on the exam chair. YOU the doctor make the diagnoses of the bunion, hammertoe etc and not the patient making his/her diagnoses so you should get paid for the e/m.

In this age of google, most patients coming to the doctor already made (or know) their diagnoses, they know what is causing their pain but we still bill for the e/m at the visit. So the argument that the 20 y/o healthy male comes back and already knows the diagnoses is not different than a patient coming in and saying I have a bunion but then don't you still bill an e/m for the "obvious" bunion.

 

[619]

I see this somewhat regularly. On the new patient I will bill the e/m and the matrixectomy with the same dx when there is no infection. If that same patient comes in a few months later and I do nothing other than walk in the room, look at the toe and go “yup, let’s do the other side,” (again, absent any other dx including infection) then I personally just bill the procedure code. Like I said, this is a common scenario that I’m curious know how people are billing and how they are justifying. Might just change the way I bill. But I will say the people who refuse to answer the question are likely doing so because they know what they are doing is questionable and they don’t want to broadcast it…

If your patient is making the diagnoses for you, then why are you the doctor? Regardless if you diagnosed the patient with an ingrown nail few months ago on the other foot. This is a NEW PROBLEM on a different foot, you still have to do a regular workup and come up with a diagnoses and treatment plan. It sounds easy and I guess you don't believe that you should paid for the e/m but then going to school for over 10 years makes everything easy and you should get paid for it.

Truth is, the majority of things we see day to day in clinic appears easy and routine but then again that is because of the extensive training we all had. And we should get paid for the work we do.

YOU the doctor makes the final diagnoses regardless of what the patient tells you. That is why you bill an e/m and that is my justification for billing the e/m.

 

[dtrack22]

For me, I always add the pain code. so it will be 99213 - 25 with M79.67x and 11750 - T5 with L60.0

See, this is what I'm talking about. Podiatrists telling their associates you can't bill pain codes as a primary dx for e/m. But clearly you can, and it gets paid.

So the argument that the 20 y/o healthy male comes back and already knows the diagnoses is not different than a patient coming in and saying I have a bunion but then don't you still bill an e/m for the "obvious" bunion.

No, that's not even close to the argument. You have to discuss billing/coding within the confines of clearly stated billing and coding rules that have been put in place. Your entire argument is that you feel like you should get paid because you feel like you did the work. And I don't disagree that we should get paid. But nowhere in your post did you explain how your opinion on coding falls within certain CMS rules, which are clear in stating that CPT code reimbursements cover pre-procedure decision making on the day of the procedure. I simply believe that the scenario I described, in which you do not have to take or review a medical/surgical history and your exam consists of a quick look at the skin before deciding to do the procedure, doesn't have a great reason to justify an e/m. If that same person actually looked infected? e/m. If they want to talk about a fungal nail? e/m. If a deformity is causing the ingrown and we talk about that? e/m. And that's not even mentioning the -25 modifier arguments. I'm just not sure how you squeeze the pain e/m on the same toe as the procedure and claim "significant, separately identifiable." This might be a better way to look at it. Let's say BCBS gets that claim you just coded above and they don't pay out the e/m, only the CPT. What is the letter that you are writing going to say? Because it can't say that you feel like they owe you the money because you're a doctor and you feel like you did more work than the CPT is worth and you feel like billing the e/m makes it so you are fairly compensated. How would you explain to them that the pain code e/m with 25 modifier and matrixectomy on the same toe falls within CMS rules and NCCI edits and that you should be paid in full?

It sounds easy and I guess you don't believe that you should paid for the e/m but then going to school for over 10 years makes everything easy and you should get paid for it.

We should get paid for our work. But unless you go to a cash practice, there are some rules that are supposed to be followed. Those rules often times have some room for interpretation, which is the whole point of these discussions. I'm not arguing that we should or shouldn't get paid for the e/m. I'm asking how you justify coding the way you and NobodyDPM (if he/she ever answers) do for a scenario as described.

 

[GreenHousePub]

You answered my question above with “there is always pain attached.” So let’s try this again.

healthy 20 yo comes in 4 months after left hallux matrixectomy. Complains of “the same problem starting on my right big toe.” Has tenderness to palpation of the right hallux later border. Some swelling but no gross erythema or drainage. He wants “the same thing you did on my other toe” and you agree. You do a matrixectomy on the lateral border of the right hallux.

That’s the scenario I described above that several folks say they will bill an e/m on. Nothing wrong with that. But how are people who are billing the e/m in a situation like that coding it?

99213 - 25 with what dx?
11750 - T5 with I’m assuming L60.0?

I see this somewhat regularly. On the new patient I will bill the e/m and the matrixectomy with the same dx when there is no infection. If that same patient comes in a few months later and I do nothing other than walk in the room, look at the toe and go “yup, let’s do the other side,” (again, absent any other dx including infection) then I personally just bill the procedure code. Like I said, this is a common scenario that I’m curious know how people are billing and how they are justifying. Might just change the way I bill. But I will say the people who refuse to answer the question are likely doing so because they know what they are doing is questionable and they don’t want to broadcast it…

For that I'd bill a straight 11750 with L600, L603, and M79674. If HMO then I'd bill a 99213 for the visit and request a 11750.

 

[NobodyDPM]

See, this is what I'm talking about. Podiatrists telling their associates you can't bill pain codes as a primary dx for e/m. But clearly you can, and it gets paid.


No, that's not even close to the argument. You have to discuss billing/coding within the confines of clearly stated billing and coding rules that have been put in place. Your entire argument is that you feel like you should get pain because you feel like you did the work. And I don't disagree that we should get paid. But nowhere in your post did you explain how your opinion on coding falls within certain CMS rules, which are clear in stating that CPT code reimbursements cover pre-procedure decision making on the day of the procedure. I simply believe that the scenario I described, in which you do not have to take or review a medical/surgical history and your exam consists of a quick look at the skin before deciding to do the procedure, doesn't have a great reason to justify an e/m. If that same person actually looked infected? e/m. If they want to talk about a fungal nail? e/m. If a deformity is causing the ingrown and we talk about that? e/m. And that's not even mentioning the -25 modifier arguments. I'm just not sure how you squeeze the pain e/m on the same toe as the procedure and claim "significant, separately identifiable." This might be a better way to look at it. Let's say BCBS gets that claim you just coded above and they don't pay out the e/m, only the CPT. What is the letter that you are writing going to say? Because it can't say that you feel like they owe you the money because you're a doctor and you feel like you did more work than the CPT is worth and you feel like billing the e/m makes it so you are fairly compensated. How would you explain to them that the pain code e/m with 25 modifier and matrixectomy on the same toe falls within CMS rules and NCCI edits and that you should be paid in full?



We should get paid for our work. But unless you go to a cash practice, there are some rules that are supposed to be followed. Those rules often times have some room for interpretation, which is the whole point of these discussions. I'm not arguing that we should or shouldn't get paid for the e/m. I'm asking how you justify coding the way you and NobodyDPM (if he/she ever answers) do for a scenario as described.

Bold mine. That is your opinion. Which you are entitled to. But not the reality I have seen in practice. As long as you document what is necessary for an E/M code, in the scenario you describe, you have every right to bill an E/M and get paid for it.

 

[HardRoadPaved]

See, this is what I'm talking about. Podiatrists telling their associates you can't

If I had a nickel any line started with this...

If we cant bill "pain" for an e/m, then my PCP cant bill "cough" or other vague diagnoses for their e/m.

 

[Scrantonicity]

*Stares at gnarly looking ingrown toenail

"Does it hurt?"

"No, not really--I've gotten used to it I guess. I just came in cause my mom saw it"

"Come on, it hurts. It hurts bad, doesn't it?"

"Well OK a little, especially when I kick something"

*Diagnoses pain in right foot, bills E/M code

Simple!

 

[PeaJay]

I see 15-20 patients in clinic 3 days per week and have a morning of surgery. With that I end up doing shy of 600wRVu per month. That’s around 75th percentile of MGMA production. So I’m plenty aggressive with how I bill. Apparently just not aggressive enough since I don’t put e/m codes and 25 modifiers on every single visit…

I need to learn your ways

20 patients x 3 days = 60 patients per week

60 patients per week x 4 weeks = 240 patients per month

600 wRVU / 240 patients = 2.5 wRVU per visit

I think I bill aggressively and I do 1.8 wRVU on average. I mean a 99203 is 1.6 wRVU and 99204 is 2.6 wRVU.

 

[HardRoadPaved]

There's your issue... Youre not billing above level 3s or youre not 25 many things. Drop the C&C too

 

[air bud]

Yeah 1.8 is not um, aggressive....

 

[dtrack22]

Yeah 1.8 is not um, aggressive....

True. I had a buddy who had a month where he was at 3 wRVU per encounter. But he’s normally like 2.3-2.6.

And I’m not quite that high because I do have a clinic day once a month outside of the schedule I posted that generates a decent number of wRVUs and my surgical wRVUs are paid at 100% for every procedure. Throw in a wound care consult or inpatient consult here and there and I’m probably more like 2.3 wRVU per encounter.

 

[G0dFather]

The other day I sat down looking at the rates of our good payors because I want to go after our bad payors. The simple truth is if insurance paid me 100% of 2021 Medicare rate for E&M and imaging for most payors that would be a big improvement. Some in office CPT is fine ie. $110 for warts of $125 for an ulcer, but a lot of the rest ideally would be 150-155% of Medicare. ie. that puts injections into the $80ish range and matrixectomy at about $240. However, outpatient surgery really needs to be at least 190% of Medicare to ultimately be worthwhile and it would still be less than old school docs got paid. If Medicare took everything over tomorrow and I only got paid $550-650 or whatever for a 1st MPJ and lapidus for the rest of my career I would do what I think godfather suggested. I would drop my surgery days per month down to ...1-2 days and cram everything in that day.

you have the right idea

Old practitioner was very generous. We also saw eye to eye on many things. I saw his taxes and accounting documents and he grossed over 300k 3 years straight working about 25hrs a week.

200k buyout 50k down and 7 year contract with 3% interest payments made quarterly. Payments work out to be just under 6k a quarter. Overall cost will be ~215k

For what its worth now you over paid but you dragged it out so it may even out or go positive in your favor due to the hyperinflantionary environment we have entered but great move none the less!! ... try to always push for 1x net or less for your next one or leverage your experience now from this and start another one cold to save more money

 

[PeaJay]

Yeah 1.8 is not um, aggressive....

Yeah, my msg expectations include c&c which lowers the numbers significantly. I thought from previous posts that dtrack had a similar set up as me (obviously a miss understanding). Mix of clipping nails to fixing ankles. Wish I could drop those worthless 0.54 wRVU 11721 nail visits

Edit: Thankfully the msg pays me well above the survey averages for my productivity level to account for forced c&c

 

[underwood]

Regarding PP, how common is it to try to obtain some employed position (2-3 days a week as an associate, nursing homes, anything really) while opening up own clinic the other days (or even buying out and slowly growing it)?
Also how many PP owners have one location vs 2-3? A lot of my current attendings have 2 locations and some also recommend timesharing 1-2 days a week at a location rather than renting entire office space to keep overhead down.

 

[NobodyDPM]

Regarding PP, how common is it to try to obtain some employed position (2-3 days a week as an associate, nursing homes, anything really) while opening up own clinic the other days (or even buying out and slowly growing it)?
Also how many PP owners have one location vs 2-3? A lot of my current attendings have 2 locations and some also recommend timesharing 1-2 days a week at a location rather than renting entire office space to keep overhead down.

I highly doubt anyone would hire an employee physician knowing they are building up their own practice at another location. Now if you are employed, working towards a buy out (which you shouldn't do for a huge number of reasons, unless the terms are written out when you are hired), that might be different.

Many have more than one office. Some don't. It's hard to know the hard numbers on that. And it is different depending on where you are. Someone practicing rurally will likely only have one office. Suburban areas, it's more likely that a practitioner, will have more than one location, to serve the surrounding locales better. But that also differs. It's hard to say for sure. It also depends on the size of the practice itself. More doctors generally means more locations.

 

[HardRoadPaved]

If you can run a full schedule at one location then why open a second location and have to increase operational costs. Thus if you plan on opening cold make sure you only have to open once by choosing the right place.

 

[G0dFather]

I need to learn your ways

20 patients x 3 days = 60 patients per week

60 patients per week x 4 weeks = 240 patients per month

600 wRVU / 240 patients = 2.5 wRVU per visit

I think I bill aggressively and I do 1.8 wRVU on average. I mean a 99203 is 1.6 wRVU and 99204 is 2.6 wRVU.

At that patient count this would be an office that generates about 300k .... slow office but not very slow

 

[dtrack22]

At that patient count this would be an office that generates about 300k .... slow office but not very slow

That’s one of the perks of hospital/large MSG employment. The schedule/patient volume above is mine and I get paid more than $300k to see that number of patients. Helps when the clinic can charge a $75 facility fee that insurance will pay for on top of whatever e/m and CPT that gets billed…

The rules hospitals have convinced the gov to create especially for them, and the things they are able to get away with is a big contributor to ever increasing healthcare costs IMO. Would be nice to see their reimbursements get cut as opposed to reimbursements for actual clinician work.

 

[air bud]

That’s one of the perks of hospital/large MSG employment. The schedule/patient volume above is mine and I get paid more than $300k to see that number of patients. Helps when the clinic can charge a $75 facility fee that insurance will pay for on top of whatever e/m and CPT that gets billed…

The rules hospitals have convinced the gov to create especially for them, and the things they are able to get away with is a big contributor to ever increasing healthcare costs IMO. Would be nice to see their reimbursements get cut as opposed to reimbursements for actual clinician work.

Yeah I have never heard the word NO working at critical access hospitals...

Also wanted to add this in. Talking to my Ortho partner the other day, he said man if I had known you were going to be this busy we would have gotten a podiatrist a long time ago. Opportunities are out there, just have to find them.

 

[G0dFather]

That’s one of the perks of hospital/large MSG employment. The schedule/patient volume above is mine and I get paid more than $300k to see that number of patients. Helps when the clinic can charge a $75 facility fee that insurance will pay for on top of whatever e/m and CPT that gets billed…

The rules hospitals have convinced the gov to create especially for them, and the things they are able to get away with is a big contributor to ever increasing healthcare costs IMO. Would be nice to see their reimbursements get cut as opposed to reimbursements for actual clinician work.

that would come to about 200K extra and the cpt/em in those facilities are reimbursed a bit less than office fees... but lets just say that your rev is 500k when you combine both numbers, you would have to generate alot of ancillary rev for the hospital to make it worth paying you that much of a percentage no ? unless your whole package is like 25 percent of your rev assuming your bringing in for them 1 mill plus from just 250 pts a month ... we see that in a mildly busy week

 

[air bud]

that would come to about 200K extra and the cpt/em in those facilities are reimbursed a bit less than office fees... but lets just say that your rev is 500k when you combine both numbers, you would have to generate alot of ancillary rev for the hospital to make it worth paying you that much of a percentage no ? unless your whole package is like 25 percent of your rev assuming your bringing in for them 1 mill plus from just 250 pts a month ... we see that in a mildly busy week

Yeah that is not how this works.

 

[heybrother]

that would come to about 200K extra and the cpt/em in those facilities are reimbursed a bit less than office fees... but lets just say that your rev is 500k when you combine both numbers, you would have to generate alot of ancillary rev for the hospital to make it worth paying you that much of a percentage no ? unless your whole package is like 25 percent of your rev assuming your bringing in for them 1 mill plus from just 250 pts a month ... we see that in a mildly busy week

You know how you sometimes can get a breakdown of what you do in your office or a facility and can see that part is appropriated to the office and part is appropriated to the provider. So you see that and you think - well the hospital people have the doctor portion and the facility portion. Except there's no correlation between them and us at all. Their numbers are just absurd compared to ours. The hospital people are not splitting $75 for a 99213 with the doctor and the facility - they are getting a much larger number.

I've given this story before but the local hospitals near me get 10x what I get from my insurance for xrays compared to what my office gets paid by my insurance. Their fee schedule does not distinguish trauma verse services provided in an ortho office on campus.

I was reading on a financial forum the other day a person complaining about being charged $1000 for a venous duplex. All these people were talking about life saving care and blah blah blah. But its all crap because the hospital essentially bills all services provided as if they were critical.

Medicare is sort of catching on to this. They are looking at hospital purchases of outpatient clinics and services provided that are outpatient off campus/not in a hospital and in some cases they are going to drop those locations down to the regular physician fee schedule and not the Medicare hospital fee schedule. It will be slow and the hospital union is fighting it like crazy.

 

[dtrack22]

but lets just say that your rev is 500k when you combine both numbers, you would have to generate alot of ancillary rev for the hospital to make it worth paying you that much of a percentage no ?

Hospitals aren’t going to hire you to break even, but they can afford to pay you nearly 100% of what you collect on e/m and CPT codes. The numbers you provided work out nicely to explain that. $300k of revenue just off of e/m and CPTs, $200k in facility fees, for $500k of total revenue. Let’s just say you were a private solo doc (or a small group so overhead is slightly reduced) and you grossed $500k. If your overhead was 40% (on the real low end but it’s not crazy) you could pay yourself $300k before taxes. The hospital based practice’s “facility fees” are basically insurance companies and patients paying that “overhead” number separate from the work done by the Doctor. So a hospital who has a doc that generates $500k in revenue can justifiably be paid around $300k without the hospital losing money.

Of course, I take cases to their OR every week. I ordered 3 MRIs today. I referred to General Surgery and ordered non invasive vascular studies. All of the labs I order are done in house. Many of my patients use the hospitals pharmacy for their prescriptions. Even a not very busy podiatrist generates $1-2 million in downstream revenue. So yes, in reality you are generating a lot of other revenue outside of even your e/m and CPT codes and office based facility fees.

unless your whole package is like 25 percent of your rev assuming your bringing in for them 1 mill plus from just 250 pts a month ...

It’s like virtually every other large MSG or hospital based job. I get paid based on what I do and the associated wRVU value

 

[air bud]

My buddy just did an in office plantar fasciotomy. Got paid 461 dollars. Guess how much the hospital would have made on that case...Facility fee, anesthesia, labs, etc.

 

[heybrother]

My buddy just did an in office plantar fasciotomy. Got paid 461 dollars. Guess how much the hospital would have made on that case...Facility fee, anesthesia, labs, etc.

That's 90% of Medicare in my locality which is better than many of my contracts. Your friend was smart - by doing it in the office they theoretically made like $140 more than they would have made at a facility. I did a bilateral at a center for just under $1k the other day. I essentially discharged the patient at the 2nd post-op when sutures were removed. Pushed their next follow-up into the future and said cancel if you are doing well.

 

[air bud]

That's 90% of Medicare in my locality which is better than many of my contracts. Your friend was smart - by doing it in the office they theoretically made like $140 more than they would have made at a facility. I did a bilateral at a center for just under $1k the other day. I essentially discharged the patient at the 2nd post-op when sutures were removed. Pushed their next follow-up into the future and said cancel if you are doing well.

Well the point was more to show how much hospitals make...also I would sacrifice 140 if it saves me 2 hours of my life at the hospital in for 5 mins.

 

[heybrother]

Well the point was more to show how much hospitals make...also I would sacrifice 140 if it saves me 2 hours of my life at the hospital in for 5 mins.

I more than get what you are saying, but I figure people have to tire of me writing "hospitals get more money for the same service" over and over.

 

[G0dFather]

Yeah that is not how this works.

But what he went on to explain is basically what i said, do you have a diff explanation ?

Even a not very busy podiatrist generates $1-2 million in downstream revenue.

Right, so would you agree that at end of day your are getting a percentage of your overall revenue creation thats at least 25 percent .. ie. you create 500k from pt interaction etc plus at least another 500k for ancill for the hospital to be ok with you seeing 60 pts a week

 

[underwood]

Congrats to OP!!

Just to add my 2 cents. I keep seeing people talk about attrition rate and what note. We are a specialists and the goal is to get new patients on your schedule and not hold on to old patients. I want my practice to be a revolving door, I want to see more new patients than follow-ups. For example, Patient comes in for heel pain, within 3 visits or less, they should be better and discharged to make room for more new patients. There is no reason to hold on to patients and string them along with unnecessary treatments. So obviously anyone who buys a practice would and should expect some "loss of old patients" but then I see it as a good thing because it makes space for "new patients" to get in which is where the money is. The old pods are struggling because they get comfortable with the diabetic nail care and fill up their schedules with nails and calluses. No reason to buy a practice and hold on to that. It's a blessing for the nails/calluses to go away and get the new patients in.

And regardless of how much OP paid for the practice, the decision he made is a million times better than being an associate for another pod. No doubt in his first year, he will take home 1.5x or 2x an associate salary and this is after taking out business expenses. In the 2nd year, 3rd year and beyond, an associates income will be peanuts compared to what OP will be making. I am saying this from a first hand experience.

The sky is the limit once you own your practice.

Any way I can PM you?

 

[619]

Any way I can PM you?

Sure

 

[underwood]

Sure

I’m unable to direct message you

 

[deleted1138023]

Any update OP on how your practice is going now?

 

[Feli]

Any update OP on how your practice is going now?

Check IPED on FB?

Yeah, hope all is well.
Getting an office off the ground or doing a fixer-upper is a 7 days per week gig for quite awhile.
I can imagine why one wouldn't have much time for SDN while doing it.

 

[icebreaker32]

OP's last post was a couple months ago on this site advising someone not to choose podiatry because of the poor ROI

 

[heybrother]

OP's last post was a couple months ago on this site advising someone not to choose podiatry because of the poor ROI

So good news - the OP is alive.

Its tough out there in PP land. I have in front of me right now a "bid" for health insurance for the office. Its for Blue Choice PPO and Blue Advantage HMO. My partner told me he wants to reduce costs (his words - "pay as little as possible") and wants an HSA. Went through the whole packet. Everything is more expensive than what we currently have. Need to get our exact current number but I think we'd lose $100/employee per month if we switched to anything. Sort of a bummer but always worth checking what the costs are out there.

I will say the whole experience is fascinating ie. there are a ton of BCBS plans and you can somewhat focus on deductible vs copays and what not. Its also interesting fascinating to see how much it costs to get platinum quality insurance ie. when someone comes in with essentially no deductible / tiny copay and high co-insurance. Gotta say I wish I was the kind of employer who could afford to give his employees great benefits - but I am not.

 

[air bud]

So good news - the OP is alive.

Its tough out there in PP land. I have in front of me right now a "bid" for health insurance for the office. Its for Blue Choice PPO and Blue Advantage HMO. My partner told me he wants to reduce costs (his words - "pay as little as possible") and wants an HSA. Went through the whole packet. Everything is more expensive than what we currently have. Need to get our exact current number but I think we'd lose $100/employee per month if we switched to anything. Sort of a bummer but always worth checking what the costs are out there.

I will say the whole experience is fascinating ie. there are a ton of BCBS plans and you can somewhat focus on deductible vs copays and what not. Its also interesting fascinating to see how much it costs to get platinum quality insurance ie. when someone comes in with essentially no deductible / tiny copay and high co-insurance. Gotta say I wish I was the kind of employer who could afford to give his employees great benefits - but I am not.

It's almost like, and hear me out.....we didn't couple employment and health insurance...

 

[heybrother]

It's almost like, and hear me out.....we didn't couple employment and health insurance...

Podiatry has at times led me to question how "benefits" and employment intersect.

 

[Adam Smasher]

OP's last post was a couple months ago on this site advising someone not to choose podiatry because of the poor ROI

Sad, I read page 1 without noting the dates and was getting excited for him

 

[619]

I will say the whole experience is fascinating ie. there are a ton of BCBS plans and you can somewhat focus on deductible vs copays and what not. Its also interesting fascinating to see how much it costs to get platinum quality insurance ie. when someone comes in with essentially no deductible / tiny copay and high co-insurance. Gotta say I wish I was the kind of employer who could afford to give his employees great benefits - but I am not.

These are mostly govt employees; The school teachers, fire fighters, police officers etc. When I get patients like these, I start doing the money dance before I even walk into the room.

 

[Shiyuan]

When I get patients like these, I start doing the money dance before I even walk into the room.

For my rebuttal to that (on some occasions), I reference my previously posted meme:

 

[HardRoadPaved]

For my rebuttal to that (on some occasions), I reference my previously posted meme:

View attachment 364776

Or when they say... "So my foot and ankle orthopedist said they dont do nail care, so I'm here"

 

[Adam Smasher]

Or when they say... "So my foot and ankle orthopedist said they dont do nail care, so I'm here"

I don't have too many of those. I have one patient who had a lapidus done by a FA ortho and it fused sort of dorsiflexed, so she comes to me to get the callus trimmed at 1st met base. She follows up with her surgeon every now and then just to drive them crazy. I'm sure ortho doesn't want these patients anymore than we do.

 

[heybrother]

These are mostly govt employees; The school teachers, fire fighters, police officers etc. When I get patients like these, I start doing the money dance before I even walk into the room.

I too am grateful for the insurances that keep us in business.

Or when they say... "So my foot and ankle orthopedist said they dont do nail care, so I'm here"

I was going to say I didn't think I'd ever heard this before, but then I remembered that some of the ortho PAs were doing nailcare and then punted the patients.

What I have annoying been told is - I'm here to see you about the nails and I'm seeing the ortho about the hammertoes in an hour. I try not to be petty but the only procedural specialty I want to share patient's with is woundcare. If they don't want me to examine/x-ray their Charcot then I don't want to take a sameday call about the foot being swollen.

I don't have too many of those. I have one patient who had a lapidus done by a FA ortho and it fused sort of dorsiflexed, so she comes to me to get the callus trimmed at 1st met base. She follows up with her surgeon every now and then just to drive them crazy. I'm sure ortho doesn't want these patients anymore than we do.

My suspicion is ortho simply tells them - let us know when you are ready to have it revised. Ortho F&A in my area will tell patients - don't come back until you are ready for surgery. They will do 1 shot for whatever condition and then tell the patient they can't reschedule without a new referral. I'm not paying to paint with a too broad a brush but I think they take steps to keep their schedule filled the want they want it.

 

[HardRoadPaved]

They will do 1 shot for whatever condition and then tell the patient they can't reschedule without a new referral. I'm not paying to paint with a too broad a brush but I think they take steps to keep their schedule filled the want they want it.

Honestly, I have a similar approach. If I get too ambitious getting people who are mostly better to f/u in a month to get the last 10% of their problem relieved, I have found they no show or cancel. This is even worse if they have a high deductible.