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[Scrantonicity]

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Facility fee schedule in my locality
11720 - $14
11721 - $23
11055 - $15
11056 - $22

Props to people doing what they have to do to make money / stay in business but getting 30% of this while some massive conglomerate keeps 70% is just unbelievable. This used to be a service that podiatrists just did on the side as a hustle.

I wonder how many decades it would take to pay off student loans with this business model. I make more money playing guitar for 2 hours than I could in a whole day doing this nonsense.

 

[GreenHousePub]

Facility fee schedule in my locality
11720 - $14
11721 - $23
11055 - $15
11056 - $22

Props to people doing what they have to do to make money / stay in business but getting 30% of this while some massive conglomerate keeps 70% is just unbelievable. This used to be a service that podiatrists just did on the side as a hustle.

That is the lowest fee schedule I have ever seen for those codes.

 

[619]

If I work for health drive while trying to start my own shop for like a year, will that potentially qualify me for a loan or do I HAVE to work under someone in an associate position in a PP?

For a new grad fresh out of residency, working for health drive or other locums will help qualify however you will do your self a favor and you will learn more working as an associate for another podiatrist than doing nursing home for a year. Furthermore, looking at the compensation model for health drive, 360 care etc. Fortunately (or unfortunately) you will earn more working as an associate than doing nursing home work.

Lastly, to get my loan approved for a new practice, the bank wanted me to have a side job/locum contract to show you are earning income outside your new practice. This is very easy for MD/DO because they can easily get a well paying side gig working ER, urgent care, hospitalist shifts etc. But for podiatry this is not the case because the bank does not want you to have a non-complete with your side gig. Only nursing home gigs will give you a work contract without non-complete because you are a 1099 independent contractor so I had to sign up with 360 care and show the bank that I had a locum work contract while building my new practice.

What everyone said above about nursing home gigs is accurate so I won't keep barking down that tree. I quit too after a few months and the bank up until today does not care so as along I am paying my bank note.

 

[bloxxeeey]

For a new grad fresh out of residency, working for health drive or other locums will help qualify however you will do your self a favor and you will learn more working as an associate for another podiatrist than doing nursing home for a year. Furthermore, looking at the compensation model for health drive, 360 care etc. Fortunately (or unfortunately) you will earn more working as an associate than doing nursing home work.

Lastly, to get my loan approved for a new practice, the bank wanted me to have a side job/locum contract to show you are earning income outside your new practice. This is very easy for MD/DO because they can easily get a well paying side gig working ER, urgent care, hospitalist shifts etc. But for podiatry this is not the case because the bank does not want you to have a non-complete with your side gig. Only nursing home gigs will give you a work contract without non-complete because you are a 1099 independent contractor so I had to sign up with 360 care and show the bank that I had a locum work contract while building my new practice.

What everyone said above about nursing home gigs is accurate so I won't keep barking down that tree. I quit too after a few months and the bank up until today does not care so as along I am paying my bank note.

Thanks so much for this. Do you have any guidance on resources, books or references to help learn about the intricacies of starting a practice seeing as you did that. It seems like a daunting task but I know this is the route I will eventually take so I may as well begin preparing for it now.

 

[619]

Thanks so much for this. Do you have any guidance on resources, books or references to help learn about the intricacies of starting a practice seeing as you did that. It seems like a daunting task but I know this is the route I will eventually take so I may as well begin preparing for it now.

Unfortunately there is really no resources, books or references. What helped me the most was working as an associate for about a year. Learnt a lot about billing, coding, insurance stuff etc.

 

[bloxxeeey]

Unfortunately there is really no resources, books or references. What helped me the most was working as an associate for about a year. Learnt a lot about billing, coding, insurance stuff etc.

Fair. It seems like you're doing well. How did you go about planning location, office space etc for your clinic? Running it is one thing and I feel like I can gain that knowledge through practicing with another pod but picking a practice location, building it and the background that goes in before the first patient that walks through the door is a different story.

 

[619]

Fair. It seems like you're doing well. How did you go about planning location, office space etc for your clinic? Running it is one thing and I feel like I can gain that knowledge through practicing with another pod but picking a practice location, building it and the background that goes in before the first patient that walks through the door is a different story.

True, Location is the biggest factor. I was lucky enough to find a place next to the hospital. Basically any office space close to a hospital where you will most likely be doing your surgery is a good location. Sure it will cost more but then you want to be (or close) in the medical community in your city.

After office location, setting up your LLC, business bank account, state license, DEA license, then general furnitures & office supplies, Insurance panel credentialing, EHR, staff, Insurance (malpractice, general liability etc) etc.

Basically everything starts with a location and office address. You need an office address to set up your LLC, business bank account, for insurance panel credentialing, hospital credentialing, malpractice and general liability insurance etc.

 

[deleted664048]

Question for people in PP, do you take call/consults? do you get paid extra for that? How many consults is reasonable? Do you get half clinic days to see consults?
Seeing consults after full day of work (or before) and potentially doing add ons, does not seem reasonable, unless you are getting paid a lot for that.

 

[Pronation]

Question for people in PP, do you take call/consults? do you get paid extra for that? How many consults is reasonable? Do you get half clinic days to see consults?
Seeing consults after full day of work (or before) and potentially doing add ons, does not seem reasonable, unless you are getting paid a lot for that.

Here are the answers you’re gonna get:

Private practice owners/partners: nope, don’t take call

Private practice associates/slaves: yup, take call for free because owner says it’s mandatory

 

[619]

Question for people in PP, do you take call/consults? do you get paid extra for that? How many consults is reasonable? Do you get half clinic days to see consults?
Seeing consults after full day of work (or before) and potentially doing add ons, does not seem reasonable, unless you are getting paid a lot for that.

I highly doubt any podiatrist in PP is getting paid extra to take call/consult. The only way you get paid is by billing the patients insurance and pray they don't have a high deductible. If patient does not have insurance then just know you are the lords work or count it as community service.

Doing a half clinic day to see consults at the hospital is not a good use of your time. Imagine having to round on 10 in-patients and none of them have insurance? If you see 10 patients in clinic without insurance, you collect your money at check-out. Can't request for cash from a patient in a hospital bed with pus dripping out the foot.

 

[PointyNippers]

Question for people in PP, do you take call/consults? do you get paid extra for that? How many consults is reasonable? Do you get half clinic days to see consults?
Seeing consults after full day of work (or before) and potentially doing add ons, does not seem reasonable, unless you are getting paid a lot for that.

Call is definitely an option starting out in order to get a patient base/surgeries/referrals. But aside from that, not worth the time/money for me personally

 

[619]

Call is definitely an option starting out in order to get a patient base/surgeries/referrals. But aside from that, not worth the time/money for me personally

Surgeries - Yes. I enjoy the toe amps, met head resection, I&D etc

Most patients I see at the hospital, I don't even want them to follow up with me in clinic. I have them follow up at the wound care center. To build a patient base, you are better off visiting doctors offices and handing out cards than working for free at the hospital seeing consults. When I started out seeing 2-3 patients a day, I didn't spend any time seeing hospital consults rather I visited all the PCP offices in my area and beyond for referrals and it is paying off very well 2 years later and counting.

Unfortunately, Most patients that end up at the hospital ER are there for a reason such as no insurance, non-compliant, medicaid or high deductible insurance with no money to pay their deductible so why would you want them at your clinic to build your patient base.

 

[619]

To clarify, If you work for a hospital or MSG and you are getting paid by wRVU then by all means fill up your schedule with anything and everything. You get paid regardless of insurance (or no insurance) and you can build your patient base.

But in PP, it's all about collections. That's why i don't really envy high volume clinics, most of them don't even verify insurance for new patients and put every patient on the schedule only to realize you are collecting a fraction of what you bill out.

High clinic volume does not equal high income. Burnout is real.

 

[deleted664048]

Thank you,

To clarify, If you work for a hospital or MSG and you are getting paid by wRVU then by all means fill up your schedule with anything and everything. You get paid regardless of insurance (or no insurance) and you can build your patient base.

But in PP, it's all about collections. That's why i don't really envy high volume clinics, most of them don't even verify insurance for new patients and put every patient on the schedule only to realize you are collecting a fraction of what you bill out.

High clinic volume does not equal high income. Burnout is real.

Thank you very much!
My boss wants me to see consults but a hospital is 1 hour from clinic, which is ridiculous in my opinion, to spend 2 hour just for driving to see some no insurance patient, after clinic. So basically, after working 8-5, driving 1 hour to see a consult and then rounding in the morning before clinic. Seems unreasonable, and especially it seems like 24/7 thing. He says, its only few consults per months, but 1 hour drive one way does not seem worth it. I am not getting paid enough to do that and if I would, I still do not think I would like to do that.

 

[619]

Thank you very much!
My boss wants me to see consults but a hospital is 1 hour from clinic, which is ridiculous in my opinion, to spend 2 hour just for driving to see some no insurance patient, after clinic. So basically, after working 8-5, driving 1 hour to see a consult and then rounding in the morning before clinic. Seems unreasonable, and especially it seems like 24/7 thing. He says, its only few consults per months, but 1 hour drive one way does not seem worth it. I am not getting paid enough to do that and if I would, I still do not think I would like to do that.

1 drive hour is ridiculous with this current gas prices even if the hospital is on your way home. My office is right next to the hospital and I go there everyday to grab free lunch from the doctors lounge. I still do not take call.
Also, a few consults a month will add up to weekly consults and then daily consults the more the hospitalists see you, know you and like the work that you do. It's a good way to get your name out there but then again I will not do it for an hour drive.

 

[wakaflocka88]

Thank you,

Thank you very much!
My boss wants me to see consults but a hospital is 1 hour from clinic, which is ridiculous in my opinion, to spend 2 hour just for driving to see some no insurance patient, after clinic. So basically, after working 8-5, driving 1 hour to see a consult and then rounding in the morning before clinic. Seems unreasonable, and especially it seems like 24/7 thing. He says, its only few consults per months, but 1 hour drive one way does not seem worth it. I am not getting paid enough to do that and if I would, I still do not think I would like to do that.

Follow your gut feeling. If it sounds bad, then ya likely a bad deal. That 2 hour round trip better spent with your own personal time or networking with other providers.

I have friends in SoCal that are willing to sit in traffic, driving to hospitals all around town to fight for trauma call for free. That’s silly to me. While ortho is paid $2k a day for call, regardless if they go in or not.

Your boss of course wants you to take call - the more you do/bill/see, the more money they make off your hard work.

 

[PointyNippers]

Surgeries - Yes. I enjoy the toe amps, met head resection, I&D etc

Most patients I see at the hospital, I don't even want them to follow up with me in clinic. I have them follow up at the wound care center. To build a patient base, you are better off visiting doctors offices and handing out cards than working for free at the hospital seeing consults. When I started out seeing 2-3 patients a day, I didn't spend any time seeing hospital consults rather I visited all the PCP offices in my area and beyond for referrals and it is paying off very well 2 years later and counting.

Unfortunately, Most patients that end up at the hospital ER are there for a reason such as no insurance, non-compliant, medicaid or high deductible insurance with no money to pay their deductible so why would you want them at your clinic to build your patient base.

Great point - more reasons why I definitely don't want to take call lol

 

[air bud]

Thank you,

Thank you very much!
My boss wants me to see consults but a hospital is 1 hour from clinic, which is ridiculous in my opinion, to spend 2 hour just for driving to see some no insurance patient, after clinic. So basically, after working 8-5, driving 1 hour to see a consult and then rounding in the morning before clinic. Seems unreasonable, and especially it seems like 24/7 thing. He says, its only few consults per months, but 1 hour drive one way does not seem worth it. I am not getting paid enough to do that and if I would, I still do not think I would like to do that.

literal LOL

 

[Feli]

Question for people in PP, do you take call/consults? do you get paid extra for that? How many consults is reasonable? Do you get half clinic days to see consults?
Seeing consults after full day of work (or before) and potentially doing add ons, does not seem reasonable, unless you are getting paid a lot for that.

Taking call is 100% illogical in most PP. Requiring it would usually just be a sign the office isn't busy enough to hire you or help you thrive. Same for any NH stuff. You want office >> surgery/wound care >> marketing >>>> any inpt or NH stuff (unless you enjoy it, don't have more lucritive work available, are doing it efficiently by seeing many pts per swoop, and are being well compensated... so basically nobody in PP).

It is fine to go round on your own rare pt who ends up in house for abx or foot injury or complication of wound/surgery/whatever, but you generally want to STRONGLY discourage new inpt consults by being slow to respond to them, not attracting them, not f/u rounding unless truly warranted (just quick fix and drop them a card to f/u office), etc. Not joking.

If you enjoy the inpt work or don't have better stuff to do, it makes a tiny bit of sense to garner consults if one has dedicated time at the wound center or wants that kind of wounds + grafts + amps practice (you can dump the complicated or bad/no insurance pts on that wound center/office, not your own). That is basic and boring to me, it can lead to bad hours very fast, and is certainly not the kind of work I enjoy... but it can pay well and be a decent start if it's available to a slow or startup PP. Too much of that finds me by accident already, though. I sure won't go looking for it. Be aware, you tend to "steal" a lot of other area DPMs' pts when you do that work in a metro (the pt was doing outpt ulcer care with another doc and you get consult for amp, etc), so it can make you a bit unpopular in that regard also.

Other than those two situations above of 1 = PKTY ends up inpt/ER or 2= slow and have a WCC to dump on, it is almost never an efficient use of one's PP time to be in the hospital unless you are really trying to grow and pick up new patients at any cost. That is usually a saturated metro. It can work a tiny bit if you have office in/near hospital and can stack up multiple pts to round on, do inpt surgery on, etc. Still, most of the docs you'll meet from consults will be docs who do a lot of inpt, so they'll send you (drumroll) more inpt consults. That may work veeery slowly and ineffectively to build a legit base of outpt office appts with good insurance (which is the whole point of PP in 95% of cases), but most of the calc decub, ram horn nails, tinea, gangrene 5th toe, etc that you are consulted to see inpt in the hospital won't ever make it to your office anyways - nor do you generally want it to. Those sick pts, wheelchair, poorly controlled DM, etc are not a huge problem in WCCenter, but in your office, they very well may ruin your flow.

As was said by @wakaflocka88, you are MUCH better off just marketing to the FPs and specialists who have mostly OUTpts and will send you more and more OUTpts than the hospital docs who will just give you more inpt work. Yuck. I ask the floor and ER to only call me on surgical stuff (gas, open fx, etc) and just send the rest to the office. I want to keep the ER happy, but the day they ever call me for pt I've never seen with ingrown or sprain or something that is obviously not admit or surgical, I set the record straight and ask them to splint and send to office on those... vibe is 'I'm willing to help but quite busy with scheduled pts.' Same with inpt... call me if the admission depends on my eval or procedure and I will see them if and when I can, but please don't ever call me for nonsense. You get what you allow.

...Let the hospital employ docs, residency programs, etc take the call for 400lb guy Jones fx, MedicAid kid punctures, toenails in ICU, drive the pus bus, uninsured IVDA ankle fx. They get paid whether pt payers and the hours are bad or good. PP docs do not. As @619 said, it's all collections or % in PP.
Again, in nearly any PP, you're significantly better off just making relationships with the PCPs and collecting working age pts, outpt surgery good outcomes, refers, goodwill, $$$. It's fine to be friendly with ER, inpt docs, etc (and I certainly am), but you absolutely want the message to be "I'm NOT on call, I'm busy in the office, I do want to help if truly needed and if I'm able, but again... I've got a lot of outpt work already." That's my focus... and if you play your cards right and make relationship correct, that 8-5 weekday 9-5 M-Th and 9-3 Fri office is also the focus of most of your web of PCPs who refer. Like attracts like. 🙂

 

[air bud]

Taking call is 100% illogical in most PP. Requiring it would usually just be a sign the office isn't busy enough to hire you or help you thrive. Same for any NH stuff. You want office >> surgery/wound care >> marketing >>>> any inpt or NH stuff (unless you enjoy it, don't have more lucritive work available, are doing it efficiently by seeing many pts per swoop, and are being well compensated... so basically nobody in PP).

It is fine to go round on your own rare pt who ends up in house for abx or foot injury or complication of wound/surgery/whatever, but you generally want to STRONGLY discourage new inpt consults by being slow to respond to them, not attracting them, not f/u rounding unless truly warranted (just quick fix and drop them a card to f/u office), etc. Not joking.

If you enjoy the inpt work or don't have better stuff to do, it makes a tiny bit of sense to garner consults if one has dedicated time at the wound center or wants that kind of wounds + grafts + amps practice (you can dump the complicated or bad/no insurance pts on that wound center/office, not your own). That is basic and boring to me, it can lead to bad hours very fast, and is certainly not the kind of work I enjoy... but it can pay well and be a decent start if it's available to a slow or startup PP. Too much of that finds me by accident already, though. I sure won't go looking for it. Be aware, you tend to "steal" a lot of other area DPMs' pts when you do that work in a metro (the pt was doing outpt ulcer care with another doc and you get consult for amp, etc), so it can make you a bit unpopular in that regard also.

Other than those two situations above of 1 = PKTY ends up inpt/ER or 2= slow and have a WCC to dump on, it is almost never an efficient use of one's PP time to be in the hospital unless you are really trying to grow and pick up new patients at any cost. That is usually a saturated metro. It can work a tiny bit if you have office in/near hospital and can stack up multiple pts to round on, do inpt surgery on, etc. Still, most of the docs you'll meet from consults will be docs who do a lot of inpt, so they'll send you (drumroll) more inpt consults. That may work veeery slowly and ineffectively to build a legit base of outpt office appts with good insurance (which is the whole point of PP in 95% of cases), but most of the calc decub, ram horn nails, tinea, gangrene 5th toe, etc that you are consulted to see inpt in the hospital won't ever make it to your office anyways - nor do you generally want it to. Those sick pts, wheelchair, poorly controlled DM, etc are not a huge problem in WCCenter, but in your office, they very well may ruin your flow.

As was said by @wakaflocka88, you are MUCH better off just marketing to the FPs and specialists who have mostly OUTpts and will send you more and more OUTpts than the hospital docs who will just give you more inpt work. Yuck. I ask the floor and ER to only call me on surgical stuff (gas, open fx, etc) and just send the rest to the office. I want to keep the ER happy, but the day they ever call me for pt I've never seen with ingrown or sprain or something that is obviously not admit or surgical, I set the record straight and ask them to splint and send to office on those... vibe is 'I'm willing to help but quite busy with scheduled pts.' Same with inpt... call me if the admission depends on my eval or procedure and I will see them if and when I can, but please don't ever call me for nonsense. You get what you allow.

...Let the hospital employ docs, residency programs, etc take the call for 400lb guy Jones fx, MedicAid kid punctures, toenails in ICU, drive the pus bus, uninsured IVDA ankle fx. They get paid whether pt payers and the hours are bad or good. PP docs do not. As @619 said, it's all collections or % in PP.
Again, in nearly any PP, you're significantly better off just making relationships with the PCPs and collecting working age pts, outpt surgery good outcomes, refers, goodwill, $$$. It's fine to be friendly with ER, inpt docs, etc (and I certainly am), but you absolutely want the message to be "I'm NOT on call, I'm busy in the office, I do want to help if truly needed and if I'm able, but again... I've got a lot of outpt work already." That's my focus... and if you play your cards right and make relationship correct, that 8-5 weekday 9-5 M-Th and 9-3 Fri office is also the focus of most of your web of PCPs who refer. Like attracts like. 🙂

Man, this is so opposite everything I have done the last few years....I have a lot to learn.

 

[Feli]

Man, this is so opposite everything I have done the last few years....I have a lot to learn.

Yeah, it all just depends on how you get paid.

I have a MCA kid for OR next week that has a GSW above medial mall through boot that probably missed PT bundle by 1-2cm and swerved and ended up with the bullet under calc tuber; the ER had splinted and Keflex'd and sent to my office (pimp hand strong = no phone call on that one). I basically consider that type of case doing charity in a PP setup. No joke. I coded highest level E&M (new pt, had to Rx, had to write up sx, explain sx, etc etc) and strap code to re-splint, dispensed CAM boot.. but, due to payer, that was still probably one of my poorest paying visits ($250 or 300 for MCA... maaaybe?) of that whole morning I saw him... and definitely my longest one. And my office mgr and I still had more lunch time f/u papers and phone calls to make sure case was added on. I legit considered trying to remove it in office for a half minute (no).

I never try to attract that stuff in this practice type (it would be fine and fun in residency or RVU or VA/IHS model). But for the collections model, I consider it basically donating a bit of my time to help him and keep the steady stream of ankle sprain, ingrown, etc refers flowing from ER. I used to tell the residents "you never know who has bad/no insurance but has a cousin or friend with really good insurance that they might send you," but it's more of a joke and seldom true in actuality. Like attracts like. Payer demographics are payer demographics.

I do these cases but absolutely keep it on DL and would never ask ER for more and more of them or fish for consults inpatient. For OR, he will be complex FB remove and wound I&D for CPTs (so less than $500 for MCA???), but for PP, you'd go broke fast and could hardly ever hit bonus working for those rates on any regular basis - esp with having the global afterwards. At least I didn't have to go to ER for it (I would have prob checked XR said no if they'd called since no fracture or serious neurovasc injury), and I was able to put his surgery on an upcoming day after some elective stuff. Still, I will probably spend a total of 3-5hrs on his case for less than $1k in collections total office + OR + f/u. That's crazy. If somebody in PP has to go in to ER to eval or do that OR case as a stand alone at the hospital (not in a block of cases), that's totally disastrous to your revenue for the day(s). Most Ortho has how to get paid for trauma/infections of bad payer pts figured out with call pay or BCBS rates on everything from ER. Pod PP does not have that... at all. 🙂

 

[DYK343]

Yeah, it all just depends on how you get paid.

I have a MCA kid for OR next week that has a GSW above medial mall through boot that probably missed PT bundle by 1-2cm and swerved and ended up with the bullet under calc tuber; the ER had splinted and Keflex'd and sent to my office (pimp hand strong = no phone call on that one). I basically consider that type of case doing charity in a PP setup. No joke. I coded highest level E&M (new pt, had to Rx, had to write up sx, explain sx, etc etc) and strap code to re-splint, dispensed CAM boot.. but, due to payer, that was still probably one of my poorest paying visits ($250 or 300 for MCA... maaaybe?) of that whole morning I saw him... and definitely my longest one. And my office mgr and I still had more lunch time f/u papers and phone calls to make sure case was added on. I legit considered trying to remove it in office for a half minute (no).

I never try to attract that stuff in this practice type (it would be fine and fun in residency or RVU or VA/IHS model). But for the collections model, I consider it basically donating a bit of my time to help him and keep the steady stream of ankle sprain, ingrown, etc refers flowing from ER. I used to tell the residents "you never know who has bad/no insurance but has a cousin or friend with really good insurance that they might send you," but it's more of a joke and seldom true in actuality. Like attracts like. Payer demographics are payer demographics.

I do these cases but absolutely keep it on DL and would never ask ER for more and more of them or fish for consults inpatient. For OR, he will be complex FB remove and wound I&D for CPTs (so less than $500 for MCA???), but for PP, you'd go broke fast and could hardly ever hit bonus working for those rates on any regular basis - esp with having the global afterwards. At least I didn't have to go to ER for it (I would have prob checked XR said no if they'd called since no fracture or serious neurovasc injury), and I was able to put his surgery on an upcoming day after some elective stuff. Still, I will probably spend a total of 3-5hrs on his case for less than $1k in collections total office + OR + f/u. That's crazy. If somebody in PP has to go in to ER to eval or do that OR case as a stand alone at the hospital (not in a block of cases), that's totally disastrous to your revenue for the day(s). Most Ortho has how to get paid for trauma/infections of bad payer pts figured out with call pay or BCBS rates on everything from ER. Pod PP does not have that... at all. 🙂

View attachment 359740

I would probably get a CT (If ER called me I would have got one in ED) to know if there is really a fracture or not.

My bet there is at least a hairline, open, fracture.

Edit: And these situations do suck when they come in scheduled for 15 minute "foot pain" consultation with no heads up. Happens all the time unfortunately.

 

[Pronation]

It’s funny how the private practice collections model is so different from hospital based RVU compensation. All of that inpatient pus and basically everything that the PP guys want to turn away is a total RVU jackpot.

 

[Redsting]

Yeah, it all just depends on how you get paid.

I do these cases but absolutely keep it on DL and would never ask ER for more and more of them or fish for consults inpatient. For OR, he will be complex FB remove and wound I&D for CPTs (so less than $500 for MCA???), but for PP, you'd go broke fast and could hardly ever hit bonus working for those rates on any regular basis - esp with having the global afterwards. At least I didn't have to go to ER for it (I would have prob checked XR said no if they'd called since no fracture or serious neurovasc injury), and I was able to put his surgery on an upcoming day after some elective stuff. Still, I will probably spend a total of 3-5hrs on his case for less than $1k in collections total office + OR + f/u. That's crazy. If somebody in PP has to go in to ER to eval or do that OR case as a stand alone at the hospital (not in a block of cases), that's totally disastrous to your revenue for the day(s). Most Ortho has how to get paid for trauma/infections of bad payer pts figured out with call pay or BCBS rates on everything from ER. Pod PP does not have that... at all. 🙂

View attachment 359740

It is very true. RVU based I am 100% there. Medicare, Medicaid, private, it doesn't matter.
I know someone who gets paid 22.5% of collections... This case would basically be paying the patient to let you take it out.

In residency one of the hospitals were pissed at my attendings there cause they would turn anything cash or that they knew they wouldn't get paid on away. The reasoning was that the hospital had other specialties on call that got paid to take call or worked based off RVUs. Now that I am on this side of it, I get it.

 

[CutsWithFury]

It’s funny how the private practice collections model is so different from hospital based RVU compensation. All of that inpatient pus and basically everything that the PP guys want to turn away is a total RVU jackpot.

100000000000% correct

 

[dtrack22]

I would probably get a CT (If ER called me I would have got one in ED) to know if there is really a fracture or not.

Meh a fracture in this case is irrelevant. GSWs are not “open fractures” in the sense that any urgent irrigation and debridement is needed of even remotely considered standard of care. They can get PO abx and/or a dose of IV and in the ED and follow up outpatient for foreign body and fracture management if they are neurovascular intact.

But if you want a CT to eval any fracture it’s always nice when the ED doc gets it for you. For some reason they will scan anything. Abdominal pain? CT. Headache? CT. Neck sore? CT. But convincing them to scan all trimals (for example) can be difficult.

 

[DYK343]

Meh a fracture in this case is irrelevant. GSWs are not “open fractures” in the sense that any urgent irrigation and debridement is needed or even remotely considered standard or care. They can get PO abx and/or a dose of IV and in the ED and follow up outpatient for foreign body and fracture management if they are neurovascular intact.

Multiple small metallic fragments typically means that bullet hit bone.

Not saying youre wrong and I linked a JBJS review article to back up your statements (below) but I would still probably irrigate it and wash it thouroughly, especially since it went thru a shoe.

Plus Feli is submitting for RRA soon if I remember correctly. They are going to pick that apart if it gets selected.

Management of Civilian Low-Velocity Gunshot Injuries to an... : JBJS

imizing complications.➤ There are a limited number of high-quality studies to support the use of prophylactic antibiotics for nonoperatively treated gunshot wounds.➤ Intra-articular retained bullets should be removed, while prophylactic irrigation and debridement for a transarticular bullet is...

journals.lww.com

 

[dtrack22]

Plus Feli is submitting for RRA soon if I remember correctly. They are going to pick that apart if it gets selected.

They aren’t going to select a soft tissue I&D, foreign body removal. I haven’t logged in a long time, but I don’t think you can even log that as an RRA procedure.

but I would still probably irrigate it and wash it thouroughly, especially since it went thru a shoe.

The ED doc is perfectly capable of running saline through a bullet wound. Would you go in for every nail that went through a shoe or just let the ED doc remove, irrigate, put on abx?

I mean more power to you. I’m not about to set that expectation with the ED providers for something you’d never be faulted for not doing. What Feli said about the pimp hand basically.

 

[DYK343]

They aren’t going to select a soft tissue I&D, foreign body removal. I haven’t logged in a long time, but I don’t think you can even log that as an RRA procedure.



The ED doc is perfectly capable of running saline through a bullet wound. Would you go in for every nail that went through a shoe or just let the ED doc remove, irrigate, put on abx?

I mean more power to you. I’m not about to set that expectation with the ED providers for something you’d never be faulted for not doing. What Feli said about the pimp hand basically.

I agree thats not an RRA case. I havent logged in awhile either. I dont think they chose any I&D cases either. My point there was dumb (at least assuming no complications then it could very well be RRA...)

I get your point and its a good one with stepping on the nail. Bullets thru a shoe pull more debris in with it than a nail thru a shoe does. Ive never had to operate on a nail puncture wound but I have cleaned out GSWs and found bits of shoe/sock in it. Once it hits the shoe it starts the tumble and sucks contaminates into the wound. Similar - but also very different scenarios. At least how I would treat it.

But like I linked above youre not wrong to splint, monitor, and short course ABX. Would have a crutch to stand on if lawsuit happened.

 

[Feli]

Meh a fracture in this case is irrelevant...

...But if you want a CT to eval any fracture it’s always nice when the ED doc gets it for you...

Yeah, no wrong answers. The XR report (Rad is paid per study) had said no fx but recommended CT... ER doc did not (prob paid per hour/shift). I (collections) will just do the case, get more XR, more abx, and NWB a bit after. Follow the $$$, lol.

I mainly just cared that he got to ER date of injury and was on abx, entry looked pretty good, no erythema. I have had plenty of plantar nail/screw/etc punctures develop gas or abscess and need cruciate I&D, ellipse out the wedge, or go to TMA or near BKA. The plantar ones seem more complicated (sweat and debris on sole of foot/shoe?), and delay care ones and DM are highest risk for sure.

...Agree that ABFAS is very unlikely to pick that one... they pick 90-100% screw/plate/implant cases in my exp and ppl I talk to. They want radiopaque stuff they can criticize. I think Achilles ruptures or lat stab or 2nd MPJ or plastics can be just as hard as calc fx or Jones fx or Lapidus or Evans... but it's super rare they'd pick the former set. It makes sense, I suppose. We dont photograph everything like pastic surgery does for their boards and medical-legal.

 

[619]

Even as a resident , I was found it bizarre when some attendings will cancel half day of clinic (with already scheduled patients) to take an in-patient to the OR for pus, amps etc. I have never done that and will never. My clinic patients come first. Maybe a few times in the last 2 years, I rescheduled my last patient at 4pm so I can get to the hospital to knock out a case because I don't want to be an add-on and wait till 11pm or midnight for my case.

 

[619]

It’s funny how the private practice collections model is so different from hospital based RVU compensation. All of that inpatient pus and basically everything that the PP guys want to turn away is a total RVU jackpot.

This is very important for anyone coming out of residency. Are you joining a PP or a hospital wRVU based model? We are all in the same field playing different games and scoring different ways. In previous threads here on sdn, there have been arguments about how surgery pays or does not pay.

The hospital employed folks will fight to death that surgery is where the money is which is 100% correct for their mode of compensation.

Then I found it laughable when someone from PP want to brag about how they spend hours in the OR doing a charcot recon. Or the ones in PP that post on IG the frame they spend hours working on. If you look at the EOB and see how much the so called charcot recon reimburses then you will be singing a different tune.

If you are in PP and do not own a share in the surgery center then your main collections/income will come from clinic work (not surgery) and you can make a very good income from office procedures. I understand the pressure of having to do surgery mainly caused by wanting to get board certified which is a shame. Board certification is what makes folks take free call at the hospital so they can get their numbers for surgery case review. Truth is if you are in PP, an ankle fracture is not just going to "walk" into your clinic on a weekly bases like we see ingrown nails everyday. But that is a topic for another day.

 

[heybrother]

Not touching the whole hospital employee vs PP thing. What's funny to me about a PP owner telling their associate to go across town to a hospital is that the practice would assuredly be better served if it had the patient volume just to stay open an extra hour.

Its like the owner wants you to leave the office at 5 to go cover a shift at a fast food restaurant and he's worked out a deal where he still gets 70% of your wages.

 

[deleted664048]

Not touching the whole hospital employee vs PP thing. What's funny to me about a PP owner telling their associate to go across town to a hospital is that the practice would assuredly be better served if it had the patient volume just to stay open an extra hour.

Its like the owner wants you to leave the office at 5 to go cover a shift at a fast food restaurant and he's worked out a deal where he still gets 70% of your wages.

Totally agree with you. Makes no sense. I was very open to the idea of staying open after hours, but staff members (MAs, front desk) don't want to work extra, even thought they get paid hourly, they want to go home. Some have kids, others just not willing to work longer hours.

 

[PeaJay]

On the topic of jobs, has anyone else noticed the trend towards hiring Podiatry PAs or NPs? My group just hired 2 NPs to help us out. There has been a similar trend in groups in my region. This will definitely tighten the market.

The thought for us is that we are over run in clinic and need a provider in office to help, but don’t want to hire another podiatrist as the surgical volume is just not there.

Edit: we are lucky to have one great non-operative podiatrist in our group, but hiring a non-operative provider was a nightmare in the past. It was a sea of substandard candidates.

 

[GreenHousePub]

On the topic of jobs, has anyone else noticed the trend towards hiring Podiatry PAs or NPs?

Several states don't allow this.

 

[AttackNME]

On the topic of jobs, has anyone else noticed the trend towards hiring Podiatry PAs or NPs? My group just hired 2 NPs to help us out. There has been a similar trend in groups in my region. This will definitely tighten the market.

The thought for us is that we are over run in clinic and need a provider in office to help, but don’t want to hire another podiatrist as the surgical volume is just not there.

Edit: we are lucky to have one great non-operative podiatrist in our group, but hiring a non-operative provider was a nightmare in the past. It was a sea of substandard candidates.

You guys just need more good non-op podiatrists sounds like. My group needs one too. Do they exist anymore? If only podiatry valued non-op podiatry…

 

[dtrack22]

You guys just need more good non-op podiatrists sounds like. My group needs one too. Do they exist anymore? If only podiatry valued non-op podiatry…

Let’s be honest, most of the time a practice is “too busy” it is too busy with routine foot care. Instead of needing more non-op podiatrists we could just stop cutting old people’s toenails. I get it, it’s a valuable service, blah, blah, blah. It’s below our newly required level/years of training. A medical assistant can do it. A pedicurist at the mall can do it. And the sad thing is that routine foot care is keeping a not so small % of this profession alive.

 

[wakaflocka88]

Let’s be honest, most of the time a practice is “too busy” it is too busy with routine foot care. Instead of needing more non-op podiatrists we could just stop cutting old people’s toenails. I get it, it’s a valuable service, blah, blah, blah. It’s below our newly required level/years of training. A medical assistant can do it. A pedicurist at the mall can do it. And the sad thing is that routine foot care is keeping a not so small % of this profession alive.

On top of this, how many of these routine foot care patients actually meet Medicare criteria. Every week I’ll get a few stating “I don’t trust a nail salon so I see this pod in town to cut my nails” or “the pod I use to see, their office is too dirty, so I’m here to see you.” No matter what version of a story I tell patients and refuse to do it, they just storm out in disbelief. I don’t even want to know how these crooks bill or make $ off these patients.

 

[DYK343]

On top of this, how many of these routine foot care patients actually meet Medicare criteria. Every week I’ll get a few stating “I don’t trust a nail salon so I see this pod in town to cut my nails” or “the pod I use to see, their office is too dirty, so I’m here to see you.” No matter what version of a story I tell patients and refuse to do it, they just storm out in disbelief. I don’t even want to know how these crooks bill or make $ off these patients.

THis is what I hate most about my job. Non qualifying nail/callus care that are 100% convinced they qualify.

 

[PeaJay]

Let’s be honest, most of the time a practice is “too busy” it is too busy with routine foot care. Instead of needing more non-op podiatrists we could just stop cutting old people’s toenails. I get it, it’s a valuable service, blah, blah, blah. It’s below our newly required level/years of training. A medical assistant can do it. A pedicurist at the mall can do it. And the sad thing is that routine foot care is keeping a not so small % of this profession alive.

100% this. My system allows us to put limits on the number of nail cares seen a day, but we still have to see nail care. I am now down to 6 a day max. No exceptions. No new nail or callus care only existing patients.

 

[Feli]

Several states don't allow this.

Do you mean DPMs can't supervise PAs?

NPs can do whatever they want. The only limit seems to be their imagination and confidence and ability to YouTube or have backup from MDs. 🙂

...I get the hiring NP as nails nurse like some VAs do or whatever. But for PP, an associate DPM is often same/cheaper and can do/dx more due to the specialized training.

There are still a TON of minimal or non-op DPMs available. We only have a microcosm here on SDN of mostly DPMs who care enough to talk/discuss career stuff. Almost everyone on here has avg or way above skill/training and career drive if they are interested to log in on weekends, lol. There are many more I know who read but never post. The mean/median is not that; majority had low/avg residency, does bare minimum CME, and reads Podiatry Today or PM News.

I am not just talking about just older DPMs... even many new 2023 grads will take non-op work due to minimal surgery training or willingness to forego some or all of their mediocre - even good - surgery training for decent hours+pay (many VAs, 'academic' hospital jobs, ortho group non op feeder DPM for F&A ortho, etc). There is no shame in that; people can do what they wish. However, anyone saying podiatry will change soon has to realize nothing happens fast. I see dozens of those non-op jobs whenever I look, and I have a few such DPMs who send most/all of their cases to me. That's been the case at most jobs I've ever had, and many of them were younger than I.

This is how ABPM is making such a push: DPMs who dont want or cant find surgical jobs... plus those who did a joke residency program... plus those who do try the surgical and full scope route but cant pass ABFAS. That's a very big number of ppl, even present day. I believe the new common term for choosing non-op is now usually "wound care specialist" or "primary care podiatrist"?

 

[air bud]

Hospital - only pod with a few orthos. New service line
260k salary
24k in quality metrics bonuses (6k per quarter) easy to obtain
Standard hospital benefits including 4%match
10 days call required, optional paid call 350 a day after that
240hr vacay yearly
RVU evaluation yearly, still working on it. Both parties expect minimum 500 to 600 RVUs a month. If RVU under threshold salary still guaranteed.

New ASC giant facility in the works with ability to invest.

Draw from about 80k people. 1.5 to 2 hrs to major metro.
No state tax

 

[underwood]

Got a job offer today which I think is pretty bad. I wanted your opinion.
120 k base with 30% after 500k in revenue. However they have offices throughout my entire county and the next and their non compete is 2 years which means I’d I leave I won’t be able to work in my area.

If the 30% collections kicked in after 300k…would that make this offer a lot more fair?? Trying to figure out what I should be asking for

 

[Pronation]

If the 30% collections kicked in after 300k…would that make this offer a lot more fair?? Trying to figure out what I should be asking for

30% of collections is pretty bad. Just to give you an idea how hard the mustache pod is screwing you, here is the basic math... the practice's overhead ranges somewhere from 45-55%. That means that after you get your measly portion of 30%, the owner is siphoning off anywhere from 15-25% depending on how well they overhead costs down. A 1st year associate can expect to collect 400-500k net receipts (gradual patient ramp up to ~20 patients daily). That translates to the owner siphoning off about 75-100k of your hard earned money. Btw this same workload in an MSG/hospital would generate a gross take-home of at least 250k...

 

[heybrother]

If the 30% collections kicked in after 300k…would that make this offer a lot more fair?? Trying to figure out what I should be asking for

Would still be fairly meh, but a substantial improvement since you'd have a hope and a prayer of a bonus.

Whenever I look at something like this I consider some version of the following:

-I calculate the starting kept percentage up to the bonus threshold ie. 120/300 or 120/500.

*So that's 40% up to $300 under your proposal or 24% under their proposal up to 500K.

-I consider what you'd keep in your first year of practice if the office is terrible and you start from scratch. I assume substantially lower than pronation above ie. $300K to $350K. I presume a much lower number because that's entirely possible if the office shouldn't have hired you.

-I look at the bonus itself ie. 30% is bad, but its essentially the classic podiatry value.

-I then brainstorm a variety of scenarios of how you win or lose:

$300K - you kept $120K and 40%. You didn't bonus but you theoretically didn't work hard.

$400K under their proposal. You kept 120K. You didn't bonus. $100K of your collections did literally nothing for you. You kept 30% total.

$400K under your proposal. You earned $120K base. You made a bonus of 30% on $100K so you got $150 out of $400K - 37.5%. Congrats on your bonus but you still should have been a nurse.

$500K under their proposal. You earned your $120K base above. You kept 24%. They assuredly kept more of your money than you did. If this was your second year and you brought in $350K in your first year then you worked $150K harder and didn't have a dime to show for it. Essentially your best scenario is literally not to work hard or to be busy. Classic podiatry offer - all disincentives.

$500K under your proposal. $120K base and $60K of bonus. 36%.

Soooo. The heart of this scenario is unless they negotiate with you - this is literally an offer you are likely to work substantially harder your second year and still make the same money as your first year. Terrible.

 

[underwood]

30% of collections is pretty bad. Just to give you an idea how hard the mustache pod is screwing you, here is the basic math... the practice's overhead ranges somewhere from 45-55%. That means that after you get your measly portion of 30%, the owner is siphoning off anywhere from 15-25% depending on how well they overhead costs down. A 1st year associate can expect to collect 400-500k net receipts (gradual patient ramp up to ~20 patients daily). That translates to the owner siphoning off about 75-100k of your hard earned money. Btw this same workload in an MSG/hospital would generate a gross take-home of at least 250k...

Ya I agree definitely not entirely fair compared to hospital/MSG but for a private practice job….if first year produces 400-500k that’ll be about 150-180k…. Not bad

 

[Pronation]

Ya I agree definitely not entirely fair compared to hospital/MSG but for a private practice job….if first year produces 400-500k that’ll be about 150-180k…. Not bad

Ok, but here's the next reality check... as @heybrother mentioned, 400-500k collections is for a busy practice that actually needed to hire somebody. Unfortunately this is a really mixed bag in podiatry. A significant amount of lazy, sleazy, greedy practice owners will hire an associate and make them go out and market to build up a patient base that the practice currently does not have. This translates to a crappy slow ramp up. So basically you can expect to make your measly base salary... and that's about it.

 

[underwood]

Ok, but here's the next reality check... as @heybrother mentioned, 400-500k collections is for a busy practice that actually needed to hire somebody. Unfortunately this is a really mixed bag in podiatry. A significant amount of lazy, sleazy, greedy practice owners will hire an associate and make them go out and market to build up a patient base that the practice currently does not have. This translates to a crappy slow ramp up. So basically you can expect to make your measly base salary... and that's about it.

Yea that’s true for sure… doing the best I can to evaluate how busy they actually are etc. but if they actually are quite busy then I’m assuming this is one of the better PP contacts out there… I’m yet to see 35 or 40% “bonus” in my search

 

[Boba Foot]

Has anyone heard of, or had any luck, negotiating a higher percentage for any inpatient work they do in the hospital outside of PP, given that hospital work has no overhead for the owner? Essentially, since there’s no overhead for inpatient work, could you use lack of overhead as leverage to ask for a higher percentage of inpatient work?