Starting a practice

[caliking87]

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I have read through many past posts on here about starting a practice. The most helpful of which was Feli’s detailed cost breakdown.
I got into podiatry for the private practice aspect, office visits and simple surgeries (1st ray, soft tissue) I’ve never liked the hospital setting. My main concerns with opening are closed insurance panels. The area I’d hope to open is very geriatric with roughly 30% of insured people insured through Medicare. Everyone always says private practice is dead, I hear about reimbursement cuts all the time. Is solo owner private practice doing routine podiatry still viable?

 

[podwho]

Yes. You won't be making a ton of money but if you build it up you can be on autopilot making 200-300 working 9-5. Thats a pretty good quality of life.

If thats something you can accept then yes its "viable". Join an IPA to get on insurances. Market a lot. Expect it to take 1-3 yrs for a full schedule depending on location/demand. Nothing however can make up for being a good doctor. If you suck..well good luck.

 

[Weirdy]

You could also be the guys down the street from me billing 11305 to circumvent non covered routine footcare and cutting on people who shouldn't be cut on.

That way they end up coming to me for 2nd opinions and FMLA paperwork and then disappear.

Business management.

 

[Dermato Fight Club]

Unfortunately my employees continue to ask for cost of living increases and my supplies/rent continue to increase as well.

 

[podiatryresident]

Hello everyone and happy holidays! I have a question: If you work at a podiatry practice for several months or a year and then leave to start your own practice, can you transfer the existing PPO/HMO contracts to your new practice, or would you need to apply and credential with each insurance from scratch?
Thank you so much!

 

[Homo sapien]

Hello everyone and happy holidays! I have a question: If you work at a podiatry practice for several months or a year and then leave to start your own practice, can you transfer the existing PPO/HMO contracts to your new practice, or would you need to apply and credential with each insurance from scratch?
Thank you so much!

From the couple of people I know who did, its from scratch. Now you're doing it as you with your own practice, not as an auto part of your prior practice

 

[Weirdy]

Hello everyone and happy holidays! I have a question: If you work at a podiatry practice for several months or a year and then leave to start your own practice, can you transfer the existing PPO/HMO contracts to your new practice, or would you need to apply and credential with each insurance from scratch?
Thank you so much!

If they were using 3rd party credentialing, soon as that contract expires you are responsible for getting back on with those insurances yourself.
Certain insurances don't work with any credentialing companies and rely on the individual to get onboarded (looking at you UHC).

Its like pulling teeth just trying to get on their panel because all of their "Contact Us" lines are automated bots. Almost impossible to reach a real person unless its collections/reimbursements related.

 

[Homo sapien]

If they were using 3rd party credentialing, soon as that contract expires you are responsible for getting back on with those insurances yourself.
Certain insurances don't work with any credentialing companies and rely on the individual to get onboarded (looking at you UHC).

Its like pulling teeth just trying to get on their panel because all of their "Contact Us" lines are automated bots. Almost impossible tor each a real person unless its collections/reimbursements related.

How do you even contact them. Do you look up the website for each individual insurance and find a credentialing contact number?

 

[Weirdy]

How do you even contact them. Do you look up the website for each individual insurance and find a credentialing contact number?

You can do that or go through a 3rd party credentialer like TIOPA, SPA, etc.
They basically charge you a fee to negotiate all the credentialling for you.

So you fill out the basic CAQH form, send them everything.
Have malpractice cert, hospital privileges, board cert, DEA, license ready

They'll be like hey here's the list of insurances we got you onboarded with, here's when the next re-up is due.
Some will also send you updates on changes within the insurances themselves like hey btw this guy is gonna cut your E&M by 3% next month etc.

 

[footpainhealer]

You can do that or go through a 3rd party credentialer like TIOPA, SPA, etc.
They basically charge you a fee to negotiate all the credentialling for you.

So you fill out the basic CAQH form, send them everything.
Have malpractice cert, hospital privileges, board cert, DEA, license ready

They'll be like hey here's the list of insurances we got you onboarded with, here's when the next re-up is due.
Some will also send you updates on changes within the insurances themselves like hey btw this guy is gonna cut your E&M by 3% next month etc.

Do these 3rd party IPA's ever have "closed panels"?

 

[Weirdy]

Do these 3rd party IPA's ever have "closed panels"?

Not sure what that means. Will get back to you if I do know.

 

[GreenHousePub]

Do these 3rd party IPA's ever have "closed panels"?

Yes.

 

[footpainhealer]

Yes.

Geez.
So someone that's an awesome podiatrist can start a ground up practice and legitimately be screwed due to insurance panels themselves being closed, AND the 3rd party "backups" like the IPA's also being closed?

So if an established practice wants to hire someone, they have to call whoever their insurance panel company or group is and ask if there's room to add on an additional podiatrist? And if there's not any room, the office is just screwed and can't hire anyone (for insured patients)?

Is it a non-issue in-practice basically everywhere in the country? Because I've definitely seen and heard of private practices in extremely saturated markets hiring people on and they get on board to insurances just fine.

 

[podiatryresident]

Thanks everyone. The insurance/credentialing side is the only thing holding me back from opening my own practice, so any advice or experience you shared would really mean a lot. So basically, working for another podiatrist wouldn't help for credentialing ?

 

[Boba Foot]

No, once you leave, you have to get recredentialed under your new entity. Joining a good IPA can help because you could possibly benefit from their payor rates as well as getting added to all their insurance panels. Joining an IPA is also a way to get around closed panels from certain insurance companies.

 

[footpainhealer]

No, once you leave, you have to get recredentialed under your new entity. Joining a good IPA can help because you could possibly benefit from their payor rates as well as getting added to all their insurance panels. Joining an IPA is also a way to get around closed panels from certain insurance companies.

The person above said that IPA's could also be closed when I asked. So closed insurance panels, and no room on the IPA for us, so no in-network patients?

Do these 3rd party IPA's ever have "closed panels"?

"Yes."

Am I understanding that correctly?

Also, why aren't these IPA's the "go to" way to be able to get paid for seeing patients? Seems like its easier, quicker, more money reimbursed, and not having to worry about "closed panels" (whatever closed panels even means; I am just assuming it means the insurance companies deny to make you in-network, which would just cost the insurance company MORE money if the patients still come to see me as OON wouldn't it lol).

 

[Homo sapien]

You can do that or go through a 3rd party credentialer like TIOPA, SPA, etc.
They basically charge you a fee to negotiate all the credentialling for you.

So you fill out the basic CAQH form, send them everything.
Have malpractice cert, hospital privileges, board cert, DEA, license ready

They'll be like hey here's the list of insurances we got you onboarded with, here's when the next re-up is due.
Some will also send you updates on changes within the insurances themselves like hey btw this guy is gonna cut your E&M by 3% next month etc.

Are hospital privileges specifically a requirement?

 

[Weirdy]

Are hospital privileges specifically a requirement?

May be getting it mixed up with malpractice requirements.

 

[Adam Smasher]

This is particular to my situation, but I def have to remain on staff at my hospital in order to participate in insurance plans. I know of several doctors who moved their practice out of state specifically to avoid being on staff at hospitals they want nothing to do with.

 

[Homo sapien]

This is particular to my situation, but I def have to remain on staff at my hospital in order to participate in insurance plans. I know of several doctors who moved their practice out of state specifically to avoid being on staff at hospitals they want nothing to do with.

That sounds horrible

 

[Adam Smasher]

That sounds horrible

it keeps the saturation down in my locale

 

[Creflo]

I have read through many past posts on here about starting a practice. The most helpful of which was Feli’s detailed cost breakdown.
I got into podiatry for the private practice aspect, office visits and simple surgeries (1st ray, soft tissue) I’ve never liked the hospital setting. My main concerns with opening are closed insurance panels. The area I’d hope to open is very geriatric with roughly 30% of insured people insured through Medicare. Everyone always says private practice is dead, I hear about reimbursement cuts all the time. Is solo owner private practice doing routine podiatry still viable?

When I started my solo practice, I called the main carriers (uhc, bcbs, aetna) and asked them all for a contract to be in network. They all told me no - their panels are closed. So I went original medicare only out of necessity. I never knew (still don't know) what an IPA is or how to use them, so I just stayed with original medicare only. That was years ago, and though I've probably made less than most who take insurance, I'm honestly glad they told me no as it has kept my practice operations much simpler.

 

[podiatryresident]

When I started my solo practice, I called the main carriers (uhc, bcbs, aetna) and asked them all for a contract to be in network. They all told me no - their panels are closed. So I went original medicare only out of necessity. I never knew (still don't know) what an IPA is or how to use them, so I just stayed with original medicare only. That was years ago, and though I've probably made less than most who take insurance, I'm honestly glad they told me no as it has kept my practice operations much simpler.

How is your practice running now ? Thanks

 

[Creflo]

How is your practice running now ? Thanks

Going good - after about 13 medicare and dme audits in 18 months, I got tired of the paperwork and dropped medicare and am self pay only. I feel like working under the insurance model creates a disadvantage for the patient for low cost visits. The cost of collecting the money from the insurance company now sometimes costs more than the reimbursement itself, so the level of care ultimately suffers. This is particularly true as inflation increases and reimbursement doesn't keep up.

Consider a 99213. To collect $90 you have to 1. Obtain medicare number. 2. Query to be sure it's active. 3. Query to see if there is a deductible/copay due. 4. Obtain the supplemental insurance information and see if it covers the deductible. 5. Arrange collection of the deductible/copay if applicable. 6. If deductible is not paid, send 2 letters to patient in attempt to collect deductible/copay. 7. Chart a perfect note so it survives future audit. 8. File the claim with medicare. 9. File the claim with the supplemental carrier if it didn't automatically cross over. 10. Play the game with the secondary carrier if they act like you never sent the claim. 11. Then if they audit you, you have to assemble the chart and submit it.

That's a lot of work to collect the $90, not to mention performing the service itself. If you put the energy/resources of #1 - #11 above towards the patient visit, it generally will result in a competitive advantage compared to your peers regarding the service provided. The big "if" is will the patient will bypass insurance, that's the hard part.

 

[footpainhealer]

Going good - after about 13 medicare and dme audits in 18 months, I got tired of the paperwork and dropped medicare and am self pay only. I feel like working under the insurance model creates a disadvantage for the patient for low cost visits. The cost of collecting the money from the insurance company now sometimes costs more than the reimbursement itself, so the level of care ultimately suffers. This is particularly true as inflation increases and reimbursement doesn't keep up.

That's a lot of work to collect the $90, not to mention performing the service itself. If you put the energy/resources of #1 - #11 above towards the patient visit, it generally will result in a competitive advantage compared to your peers regarding the service provided. The big "if" is will the patient will bypass insurance, that's the hard part.

As someone that wants to open a practice within the next 1-2 years, this is depressing and discouraging as heck lol.
Are there really certain payers where it cost more to get reimbursed than the amount you're actually getting reimbursed?

Instability/poor ROI being an employee anywhere, difficult to make good money being an owner apparently lol, all desirable places to live oversaturated, seven years of post college life, 200 to 500 K of student loans (yes, I had classmates <multiple> that have half-a-million in student loans for this crap due to undergrad loans), reimbursements going down instead of at the very least, keeping up with inflation.

I should just leave the US and open a practice in Mexico or Brazil or Turkey or Singapore or UAE lol

 

[Adam Smasher]

As someone that wants to open a practice within the next 1-2 years, this is depressing and discouraging as heck lol.
Are there really certain payers where it cost more to get reimbursed than the amount you're actually getting reimbursed?

The way around this is that you need staff to verify insurance eligibilities. If you're starting from the ground level, you can do it yourself but pretty soon there are better uses for your time. This is why it was such an upheaval a year and a half ago when change healthcare underwent its cyber attack, because they were the insurance clearing house that we currently no longer use who handled all of this garbage, and we basically had to go 3 months with zero cashflow.

 

[footpainhealer]

The way around this is that you need staff to verify insurance eligibilities. If you're starting from the ground level, you can do it yourself but pretty soon there are better uses for your time. This is why it was such an upheaval a year and a half ago when change healthcare underwent its cyber attack, because they were the insurance clearing house that we currently no longer use who handled all of this garbage, and we basically had to go 3 months with zero cashflow.

Gotcha. Practically speaking, does that mean I have to call each insurance company, ask them if they cover a heel injection for example for all their insured patrons in my area, and only then I should schedule said patient, or perform the injection? That seems like a dumb system. If someone wants to call and get scheduled to be seen, and they are insured, that should be the end of it. lol

When I start, I am paying someone (like a consultant or one of those companies that handles all the billing, appealing, RCM, etc.) to handle that side of it. Maybe I'll do it myself or bring it in house after a few years, but I don't mind spending a few % per transaction for stable cashflow and accurate, ethical billing.

Maybe even just pay for the whole package on EMR's where the billing and RCM is handled through the EMR provider. Is that typically cost-prohibitive? Like why would someone choose NOT to use the billing features of their EMR's? Cause to me, it seems like it would streamline everything and be less of a headache for everyone lol.

 

[air bud]

Because when you get paid pennies on the dollar and you are not that busy you will say to yourself every dollar counts and you have all the time so you're just going to do it yourself and not pay somebody. You're not made out of money


Edit - every penny counts

 

[heybrother]

My EHR does automated insurance verifications. I'm sure I'm paying for the feature. Over the years we've had a few people slip through and the number one rule is to reverify insurance the week of outpatient surgery.

Other than custom orthotics that require pre-certification and HMO visits that require referrals I see next to nothing denied in clinic other than fraudulent bullcrap ie. the league of insurance douchebags - UHC, Aetna, and Humana who'll deny anything against the wall to see what sticks.

Fun fact. United Medicare Advantage has denied NOTHING since I went out of network. Turns out that when you don't have a contract with them they can't sodomize you.

I do in clinic 5th digit resection arthroplasties, flexors, amputations, hardware removals, every sort of injection, etc and none have ever been denied as requiring an authorization across a diversity of insurances. We occasionally ask for authorization on irregular insurances or potential higher reimbursing insurances but its never been an issue.

 

[Creflo]

Below are 2 links to recent OIG podiatrists findings.

When I told my patients I'm going off Medicare due to the coding/billing/audit hassles, many of them said "just hire it out." While you can hire out some things, I wounldn't hire out proper documentation for Medicare. See below links for recent findings from medicare audits for routine foot care and e&m's with 25 mods. They hit me with an audit for e&m's with 25 mod for about 30 charts. They also hit me with an audit for routine foot care. I had prepared for it, with photos etc of pathology because I knew they targeted those notes. Thankfully I passed every chart, but if I had not passed, they could have extrapolated the 25 mod audit which could have cost me dearly and turned into big dollar amounts.

Here are the links, hopefully I posted them correctly:

Podiatrists’ Claims for Routine Foot Care Services Did Not Comply With Medicare Requirements

Podiatrists’ Claims for Evaluation and Management Services Did Not Comply With Medicare Requirements

oig.hhs.gov