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I’m a new DPM in private practice – been discussing some stuff with residents/friends who are starting the hunt and just wanted to try and put something together to share. Contributions from the many solid posters on this forum have been pretty instrumental in shaping my opinion and much of what you’ll see here has been parroted elsewhere in prior jobs threads etc.
-This has been well stated numerous times on this forum: if you want to be somewhere you have to pick up the phone. Cold call, send out resumes, etc. In fact, if you want a job in general you may have to do this. There just isn’t that much public stuff out there. I’ve scanned the easy public stuff and thought – wow, bunch of stuff and I’ve looked months later and there was literally almost nothing listed. When I scanned the lists near the end of my 3rd year I thought it looked like a famine.
-Others have said it before and better – the job you want (especially if it’s at a hospital or MSG) is not on a job board. You have to try and create it.
-While time consuming, there can be value to a personal statement – during a job interview last year I was told by the person in question that he had received more applications than he knew what to do with (like 80), but that ultimately he would likely only call people who sent statements saying “why here”.
-It is entirely possible you will never see a job you like on the classic job listing websites. In essentially 1.5 years of some degree of semi-constant looking I saw 2 that I was excited about and one was after I started my current job.
-If you are a 3rd year you will likely find that the hiring process can go way longer than you would ever believe. Communicating and chit chat. Finding time to interview. Jumping through whatever hoops and stuff are thrown at you. Signing a contract.
-The initial offer and what the contract says are often WAY OFF. I have spoken to numerous friends and this will make you cringe. The differences between what the contract stated and what was on the initial offer were miles apart in almost every single instance. It is frequently stated on here – you must absolutely have a lawyer read your contract. What I am saying is – expect there to be renegotiation and back and forth where the contract has to be changed. The almost unfortunate truth is that if you are being hired by a private practice doctor – you need to get your hands on the contract as soon as possible because until that point you won’t have any idea what the contract will look like. You are very possibly waiting for a **** show or a back and forth on every point.
-Until I received my contract I did not know whether I would have a non-compete or not. Thank god. Did not. I didn’t even want to ask because I didn’t want to give them the idea of it. (possibly a mistake, but turned out ok). If you move to a small town and sign a non-compete I hope you have a good lawyer or live in …California/Oklahoma/the one other state where they don’t apply.
-Every word and sentence of your future contract is potentially an opportunity to ensnare you. That’s a very skeptical and paranoid way to look at the process but if you go into it just saying “well they got the pay right” you may be in for a surprise.
-My contract defined a multi-year period and a plethora of reasons for which I would be fired, but did not appear to contain a way for me to quit. Now perhaps I could have just quit, but my lawyer found the whole thing too strange and we added a section. It was the only section we successfully added other than fixing a pay problem. Every other recommendation my lawyer put forward to make the contract less 1-sided was rejected. Get your contract sooner so that when you deal with unreasonable people you can walk away. Walking away after January in your 3rd year will become more difficult.
-My contract contains a clause essentially stating that this contract is the new starting line and that no prior discussions or agreements are binding – only the contract is. Consider then that if you go to the employer and ask for clarification on what a part of the contract means – will that even apply? My advice - ensure that whatever is agreed upon must be stated in the contract. If the contract states you’ll be reimbursed for medical services and your future boss assures you that includes DME too – get them to state it in the contract.
-Do not stop looking because you think something is working out. Recognize when someone is stalling, or trying to drag you out/drain you. If it seems like the goal is for the negotiation to go on until the end of 3rd year so you have to take the job – run away. My experience is that most offices don’t call people back to tell them “sorry, we’re going with someone else.” Don’t sit around waiting for a phonecall.
-You may ultimately travel to and interview for jobs where you haven’t yet been given a salary offer or an idea of compensation. If you can’t get an actual number from someone within a reasonable time period – keep looking. Exchange empty pleasantries. Tell them you loved their practice. And then find some new offers. They are probably looking to.
-I committed too much time and energy to a person who ultimately strung me along. I’ve said some variations of the details before, but basically I met someone who wanted me to buy his practice at his almost full collection value. Among my many mistakes – my visit to his office made me think he was shady as hell and he talked down to me the whole time. If the visit is rough – how do you think the job is going to be? Don’t let the things you like (location) cloud your judgement. This isn’t residency where we sometimes put up with older attendings foibles in exchange for training – there is nothing to be gained working for an dingus.
-There’s a lot of imperfection to my current job, but one thing I saw in my employer is that he has no interest in getting in my business. My personal opinion – if you get the vibe that they intend to follow you into the room, go with you to surgery, …intimately micro-manage you – run away. There’s probably some owner who would say – it’s my practice, I need to know you are treating my patient’s right! Cool, I don’t want to work there. I may feel differently when I hire an associate.
-If a person is advertising a job for years – there’s probably a good reason. There’s a guy who has been trying to fill the same position for like 3+ years. The listing doesn’t say it but he’s offering 17%. More on that later. Don’t accept that offer.
-Small towns and low cost of living do not in any way justify low pay. “This town is very affordable. Making $small-number here in this town is going to carry you so much further than in NY” is a fake argument.
-I’m not saying a 3rd year applying now is late, but you aren’t earlier. 2nd years – you are still learning. You think – I can’t start applying now, I’m still doing other stuff. I’m insecure. I don’t have my numbers. I don’t know what I want to do yet. If I talk to them they’ll say – you are too far away, we want to hire someone sooner. Eh – all wrong answers. Start looking. The biggest issue isn’t any of the above – it’s just finding a good job in general. Work with the assumption you’ll get good training (hopefully you will) and that you’ll be able to serve whatever the need is. I think the biggest issue is just finding an actual job worth taking. It is entirely possible that even though they want someone now the job will still be waiting for you in 2 years. My 2nd year got a job my 3rd year interviewed for.
-All benefits a job offers have a cash value. When your employer says the job has health insurance it means they are spending a certain amount of money to buy health insurance for you. Until you start you won’t have any idea what the quality of the plan is they bought for you (will the deductible be $3000 or $5000, deductibles, co-insurance etc). When you renew your current residency health benefits the plans often tell you how much the hospital is kicking in for the insurance and how much you are kicking in – you just have to be bored enough to look through all the documents. In general, hospital jobs are going to have substantially better benefits than private practice. For example, your private practice may offer health insurance as the only benefit. Dues, malpractice, licensing – these aren’t benefits. You can’t practice without them. Is healthcare nearly free at your hospital as a resident? On a private practice plan it won’t be.
-Do you have a family? The private practice jobs likely will not offer health insurance for them. I’m not necessarily saying that the hospital will cover your family, but the price to insure your family is likely less on a hospital type plan because they tend to have more efficient/low-cost plans either because of their number of employees or potentially because the hospital owns the insurance plan itself. Here’s an example for you – I have a healthy wife and child and I’ll essentially have $10,000 taken out of my paycheck to cover their premiums and that’s before a single visit. Pricing health insurance in my experience is difficult, but my experience looking on my own suggested a family plan is $10-20K if you had to pay on your own.
-We have in the past had semi-regular discussions about what your pay should be, collections percentages etc. Several posters have advocated that the usual amounts offered are absurd and that multi-specialty/hospital groups pay substantially higher wages – essentially the values we discuss as good are in fact horribly terrible. It may have even been suggested that values approaching 50% are possible in those arenas. Others disagree. Unfortunately, I’m rooting around in the private practice slums so I’m in the depths of that swamp.
Variations of ways people will offer you pay.
-A straight percentage all the way through. Obviously this is not very complicated. Higher is better.
-Some version of a certain base up to a certain amount of collections often followed by a different percentage of collections after that point.
-Here’s my thing on that – once you collect a certain amount of money you’ve likely paid off overhead. Obviously there are ways to make money that increase overhead, but at some point the nurses have been paid for their time, the lights have been paid, the building has been paid etc. Hospitals and MSGs and orthopedic groups recognize that –a podiatrist in an orthopedic group showed me his tiers and he definitely was better compensated at higher levels. Podiatrists in hospital groups will find their RVU dollar values increase in value as the number of RVUs generated increase.
-I don’t know of anyone in private practice with a contract that becomes increasingly lucrative in time, but I’ve seen plenty of examples in the reverse where people get screwed when their collections increase.
-There will definitely be people out there who’ll offer a contract that gets worse as you work harder.
-Consider – you are offered $100,000 up to collections of $300,000. You are then paid a “bonus” (it is not a bonus) of 20% after that point. An offer similar to this was discussed on this forum – this person is being paid 33% on their first $300K but 20% after. They are taking a paycut for working harder.
-Here’s a different variation to consider. You are offered $140,000 up to $330,000 and then offered 30% after this. What’s interesting in this scenario is that you are collecting 42% in your tier, but only collecting 30% in your 2nd tier. I’ll offer you 3 ways to think about this.
(1) Its private practice so it’s already stupid, get a job for a hospital that starts you at 200K.
(2) It is wrong to pay you less in the 2nd tier – you should be paid more there. Fight for it.
(3) By most standards $140K/42% in any tier is better than most PP. The real question is – what will your collections be. Everyone knows of someone who makes $900K – but what will you actually collect? If your collections are $450K then your ultimate collections percentage is 39%. It will decrease as your collections increase past $450K because the 30% will average it down. If you collected $900K that year you’d be paid $311K and your collections percentage would be 34.5% and someone may have made more money off your labor than you did…
-Should you work for a hospital? The starting math is hard to argue with. You are much more likely to receive (1) pay exceeding 200K to start with (2) actual benefits (all benefits have value so while I don’t subscribe a significant value to work provided life insurance, it still has a cash value and you would not have otherwise received it in PP) (3) compensation increasing benefits such as 401k+matching (4) lifestyle associated benefits such as more PTO, more vacation, more CME. (5) potentially, a decreased likelihood of having to put up with other podiatrists crap – ie. Seeing someone else’s post-ops, and heck, even if you do have to see them- you are at least being paid a real wage.
-Problems with hospitals? Without even touching dynamics of podiatry verse ortho, taking call, how people interact with you or who gets what referrals etc. – theoretically, no one should care more about your own practice than you. I say this more to describe ownership path people than associates. The hospital I was last employed by was actively screwing up the billing of every specialist that worked for them. They were screwing up the modifiers, not submitting the billing etc. They wouldn’t tell the doctors what was actually being collected and claimed it often took 6-9 months to get paid for anything. When these doctors went PP they found out this was not the case. I’m 3 weeks out and I’m actively seeing my 1st week encounters closing out/getting paid out. The previously mentioned specialists also over time watched the hospital seize their revenue streams – in office X-ray was taken, along with all DME – in office OTC orthotics, customs, CAM boots etc. In short, not all hospitals are created equal. Employment may ultimately allow better control of expenses and revenue streams
-Sadly, I’m not even done with that hospital yet. Consider that you own an office and have IT needs. Ultimately, those costs could be quantified - $10,000 or $20,000 or whatever. The hospital in question was simply charging a percentage of revenue which meant as you the doctor were more successful the percentage of your income that went to IT increased. A hospital employed doctor can be very successful, be paid a very fair wage, but in fact ultimately be under compensated compared to what they should have been paid based on their collections.
-I’ve got a job, I’ve got my numbers, I’m cruising.
Get to work on coding. I showed up at day one of my job and there were no other podiatrists there (which really, made me very happy). Thankfully, for the last 6 months of my residency I coded all of my office encounters. Every once in awhile I’d think – oh, I’ll just leave this one undone and my attending will sort it out. Guess what – that attending will be you soon. Get over to E&M University and start looking at the differences in new verse established, what is medical decision making, what are the most relevant modifiers (E&M verse procedural). My realization while reading it – I’m pretty sure I’m grossly over documenting. All of that horrible nailcare you hopefully won’t be doing - we’ve discussed this before on here – it’s a hassle and its highly regulated. There is nothing worse than not being paid for it if you already had to do it. Learn all the Q7,8,9. Learn the A,B,Cs. Learn who qualifies for calluses. Calluses pay more than nails. Go to the medicare online fee schedule search so you know what this crap actually pays.
Physician Fee Schedule Search
Select 2019, pricing information, pick single (1 code) or range HCPCS, specific locality, all modifiers, and then set the locality to your area (there’s a list). The HCPCS code is the CPT code ie. For range select 99212-99215 to see all the standard new and established E&M code values, 20550 to see a plantar fascial injection etc.
The other day I saw a new patient who I decided was a Q8. My receptionist comes to me and says we won’t be paid for the Q8 because she doesn’t have a cardiologist on file. She then explained to me that the patient has to have a doctor managing their systemic condition ie. The internist who manages their diabetes. I pulled out the guidance and showed her that the PAOD diagnoses do not have a “*” next to them and the asterisk indicates the patient requires someone else to manage their systemic problem. So jokingly, I spent 10 minutes arguing with my receptionist to justify a $35 charge. That said – highly regulated. Be like Natch – don’t learn the rules because you don’t offer the service. Or learn it because you’ll probably do more of it than you want.
-Additional things worth understanding – fracture care coding, globals, when E&Ms and CPT codes can both be used.
-What’s private practice like? Well, I would strongly recommend reading PADPMs thing at the top of the page. We work for our money. My practice only sees private insurance and Medicare. So the good news is we are probably receiving reimbursement that is about as good as it gets. In fact, some of the E&Ms and office procedures reimburse near the top of the fee schedule. That said – my patient volume is still low/growing and at the end of the day I sometimes count it out and think – I wish there had been a few more X-rays, a matrixectomy, a few injections etc. We don’t carry DME. We should but we don’t. The local DME store that gets my business keeps buying my staff milkshakes.
-Being in someone else’s office is an adjustment. The nurses are used to the other podiatrists and I’ve had to change a few “nurse educational speaches to patients” that aren’t in line with my recommendations. I STRONGLY recommend you bring with you or create educational materials to give your patient’s in line with what you already believe. My attendings had some sheets like this though after I made my own versions I comically realized they were rife with spelling errors.
-My new office does matrixectomy procedures as a sterile event – I definitely put a stop to that. They also only perform them ..twice a day at specific time points because it takes so long… I told the receptionist I don’t want an ingrown nail turned away that wants to come in. Will see if that comes back to bite me but I did 6 in one day awhile back out of a 11 patient day.
-I’m still not credentialed for surgery so I’m definitely discussing all manner of conservative care with people at present.
-Within 1 week of starting I was taken out for a steak dinner and then pitched a deal that I’m sure is a Stark Law violation.
-Coming back around to PADPM above again. I suspect it would probably be considered very poor form to tell you all what my E&Ms and CPTs pay, but again – they are good amounts and yet you would still have to pile a great deal of them together to get these big numbers people are talking about. I’m personally aiming for $400K in collections right now with hopes I can revise up in the future. I’m seeing 10 new patients a day right now and it is slowly creeping up with follow-ups. I want to get to 20. I personally feel like my office is barely open – if I told you when we stop and start you’d laugh. If you work 250 days a year you’d need $1600 in collections a day to reach 400K. Now multiply that number by your collections percentage and realize you need that number to be as big as possible if you want to make any money. Now realize what that number would have to be for you to be paid a hospital starting wage. That’s all for now.
-This has been well stated numerous times on this forum: if you want to be somewhere you have to pick up the phone. Cold call, send out resumes, etc. In fact, if you want a job in general you may have to do this. There just isn’t that much public stuff out there. I’ve scanned the easy public stuff and thought – wow, bunch of stuff and I’ve looked months later and there was literally almost nothing listed. When I scanned the lists near the end of my 3rd year I thought it looked like a famine.
-Others have said it before and better – the job you want (especially if it’s at a hospital or MSG) is not on a job board. You have to try and create it.
-While time consuming, there can be value to a personal statement – during a job interview last year I was told by the person in question that he had received more applications than he knew what to do with (like 80), but that ultimately he would likely only call people who sent statements saying “why here”.
-It is entirely possible you will never see a job you like on the classic job listing websites. In essentially 1.5 years of some degree of semi-constant looking I saw 2 that I was excited about and one was after I started my current job.
-If you are a 3rd year you will likely find that the hiring process can go way longer than you would ever believe. Communicating and chit chat. Finding time to interview. Jumping through whatever hoops and stuff are thrown at you. Signing a contract.
-The initial offer and what the contract says are often WAY OFF. I have spoken to numerous friends and this will make you cringe. The differences between what the contract stated and what was on the initial offer were miles apart in almost every single instance. It is frequently stated on here – you must absolutely have a lawyer read your contract. What I am saying is – expect there to be renegotiation and back and forth where the contract has to be changed. The almost unfortunate truth is that if you are being hired by a private practice doctor – you need to get your hands on the contract as soon as possible because until that point you won’t have any idea what the contract will look like. You are very possibly waiting for a **** show or a back and forth on every point.
-Until I received my contract I did not know whether I would have a non-compete or not. Thank god. Did not. I didn’t even want to ask because I didn’t want to give them the idea of it. (possibly a mistake, but turned out ok). If you move to a small town and sign a non-compete I hope you have a good lawyer or live in …California/Oklahoma/the one other state where they don’t apply.
-Every word and sentence of your future contract is potentially an opportunity to ensnare you. That’s a very skeptical and paranoid way to look at the process but if you go into it just saying “well they got the pay right” you may be in for a surprise.
-My contract defined a multi-year period and a plethora of reasons for which I would be fired, but did not appear to contain a way for me to quit. Now perhaps I could have just quit, but my lawyer found the whole thing too strange and we added a section. It was the only section we successfully added other than fixing a pay problem. Every other recommendation my lawyer put forward to make the contract less 1-sided was rejected. Get your contract sooner so that when you deal with unreasonable people you can walk away. Walking away after January in your 3rd year will become more difficult.
-My contract contains a clause essentially stating that this contract is the new starting line and that no prior discussions or agreements are binding – only the contract is. Consider then that if you go to the employer and ask for clarification on what a part of the contract means – will that even apply? My advice - ensure that whatever is agreed upon must be stated in the contract. If the contract states you’ll be reimbursed for medical services and your future boss assures you that includes DME too – get them to state it in the contract.
-Do not stop looking because you think something is working out. Recognize when someone is stalling, or trying to drag you out/drain you. If it seems like the goal is for the negotiation to go on until the end of 3rd year so you have to take the job – run away. My experience is that most offices don’t call people back to tell them “sorry, we’re going with someone else.” Don’t sit around waiting for a phonecall.
-You may ultimately travel to and interview for jobs where you haven’t yet been given a salary offer or an idea of compensation. If you can’t get an actual number from someone within a reasonable time period – keep looking. Exchange empty pleasantries. Tell them you loved their practice. And then find some new offers. They are probably looking to.
-I committed too much time and energy to a person who ultimately strung me along. I’ve said some variations of the details before, but basically I met someone who wanted me to buy his practice at his almost full collection value. Among my many mistakes – my visit to his office made me think he was shady as hell and he talked down to me the whole time. If the visit is rough – how do you think the job is going to be? Don’t let the things you like (location) cloud your judgement. This isn’t residency where we sometimes put up with older attendings foibles in exchange for training – there is nothing to be gained working for an dingus.
-There’s a lot of imperfection to my current job, but one thing I saw in my employer is that he has no interest in getting in my business. My personal opinion – if you get the vibe that they intend to follow you into the room, go with you to surgery, …intimately micro-manage you – run away. There’s probably some owner who would say – it’s my practice, I need to know you are treating my patient’s right! Cool, I don’t want to work there. I may feel differently when I hire an associate.
-If a person is advertising a job for years – there’s probably a good reason. There’s a guy who has been trying to fill the same position for like 3+ years. The listing doesn’t say it but he’s offering 17%. More on that later. Don’t accept that offer.
-Small towns and low cost of living do not in any way justify low pay. “This town is very affordable. Making $small-number here in this town is going to carry you so much further than in NY” is a fake argument.
-I’m not saying a 3rd year applying now is late, but you aren’t earlier. 2nd years – you are still learning. You think – I can’t start applying now, I’m still doing other stuff. I’m insecure. I don’t have my numbers. I don’t know what I want to do yet. If I talk to them they’ll say – you are too far away, we want to hire someone sooner. Eh – all wrong answers. Start looking. The biggest issue isn’t any of the above – it’s just finding a good job in general. Work with the assumption you’ll get good training (hopefully you will) and that you’ll be able to serve whatever the need is. I think the biggest issue is just finding an actual job worth taking. It is entirely possible that even though they want someone now the job will still be waiting for you in 2 years. My 2nd year got a job my 3rd year interviewed for.
-All benefits a job offers have a cash value. When your employer says the job has health insurance it means they are spending a certain amount of money to buy health insurance for you. Until you start you won’t have any idea what the quality of the plan is they bought for you (will the deductible be $3000 or $5000, deductibles, co-insurance etc). When you renew your current residency health benefits the plans often tell you how much the hospital is kicking in for the insurance and how much you are kicking in – you just have to be bored enough to look through all the documents. In general, hospital jobs are going to have substantially better benefits than private practice. For example, your private practice may offer health insurance as the only benefit. Dues, malpractice, licensing – these aren’t benefits. You can’t practice without them. Is healthcare nearly free at your hospital as a resident? On a private practice plan it won’t be.
-Do you have a family? The private practice jobs likely will not offer health insurance for them. I’m not necessarily saying that the hospital will cover your family, but the price to insure your family is likely less on a hospital type plan because they tend to have more efficient/low-cost plans either because of their number of employees or potentially because the hospital owns the insurance plan itself. Here’s an example for you – I have a healthy wife and child and I’ll essentially have $10,000 taken out of my paycheck to cover their premiums and that’s before a single visit. Pricing health insurance in my experience is difficult, but my experience looking on my own suggested a family plan is $10-20K if you had to pay on your own.
-We have in the past had semi-regular discussions about what your pay should be, collections percentages etc. Several posters have advocated that the usual amounts offered are absurd and that multi-specialty/hospital groups pay substantially higher wages – essentially the values we discuss as good are in fact horribly terrible. It may have even been suggested that values approaching 50% are possible in those arenas. Others disagree. Unfortunately, I’m rooting around in the private practice slums so I’m in the depths of that swamp.
Variations of ways people will offer you pay.
-A straight percentage all the way through. Obviously this is not very complicated. Higher is better.
-Some version of a certain base up to a certain amount of collections often followed by a different percentage of collections after that point.
-Here’s my thing on that – once you collect a certain amount of money you’ve likely paid off overhead. Obviously there are ways to make money that increase overhead, but at some point the nurses have been paid for their time, the lights have been paid, the building has been paid etc. Hospitals and MSGs and orthopedic groups recognize that –a podiatrist in an orthopedic group showed me his tiers and he definitely was better compensated at higher levels. Podiatrists in hospital groups will find their RVU dollar values increase in value as the number of RVUs generated increase.
-I don’t know of anyone in private practice with a contract that becomes increasingly lucrative in time, but I’ve seen plenty of examples in the reverse where people get screwed when their collections increase.
-There will definitely be people out there who’ll offer a contract that gets worse as you work harder.
-Consider – you are offered $100,000 up to collections of $300,000. You are then paid a “bonus” (it is not a bonus) of 20% after that point. An offer similar to this was discussed on this forum – this person is being paid 33% on their first $300K but 20% after. They are taking a paycut for working harder.
-Here’s a different variation to consider. You are offered $140,000 up to $330,000 and then offered 30% after this. What’s interesting in this scenario is that you are collecting 42% in your tier, but only collecting 30% in your 2nd tier. I’ll offer you 3 ways to think about this.
(1) Its private practice so it’s already stupid, get a job for a hospital that starts you at 200K.
(2) It is wrong to pay you less in the 2nd tier – you should be paid more there. Fight for it.
(3) By most standards $140K/42% in any tier is better than most PP. The real question is – what will your collections be. Everyone knows of someone who makes $900K – but what will you actually collect? If your collections are $450K then your ultimate collections percentage is 39%. It will decrease as your collections increase past $450K because the 30% will average it down. If you collected $900K that year you’d be paid $311K and your collections percentage would be 34.5% and someone may have made more money off your labor than you did…
-Should you work for a hospital? The starting math is hard to argue with. You are much more likely to receive (1) pay exceeding 200K to start with (2) actual benefits (all benefits have value so while I don’t subscribe a significant value to work provided life insurance, it still has a cash value and you would not have otherwise received it in PP) (3) compensation increasing benefits such as 401k+matching (4) lifestyle associated benefits such as more PTO, more vacation, more CME. (5) potentially, a decreased likelihood of having to put up with other podiatrists crap – ie. Seeing someone else’s post-ops, and heck, even if you do have to see them- you are at least being paid a real wage.
-Problems with hospitals? Without even touching dynamics of podiatry verse ortho, taking call, how people interact with you or who gets what referrals etc. – theoretically, no one should care more about your own practice than you. I say this more to describe ownership path people than associates. The hospital I was last employed by was actively screwing up the billing of every specialist that worked for them. They were screwing up the modifiers, not submitting the billing etc. They wouldn’t tell the doctors what was actually being collected and claimed it often took 6-9 months to get paid for anything. When these doctors went PP they found out this was not the case. I’m 3 weeks out and I’m actively seeing my 1st week encounters closing out/getting paid out. The previously mentioned specialists also over time watched the hospital seize their revenue streams – in office X-ray was taken, along with all DME – in office OTC orthotics, customs, CAM boots etc. In short, not all hospitals are created equal. Employment may ultimately allow better control of expenses and revenue streams
-Sadly, I’m not even done with that hospital yet. Consider that you own an office and have IT needs. Ultimately, those costs could be quantified - $10,000 or $20,000 or whatever. The hospital in question was simply charging a percentage of revenue which meant as you the doctor were more successful the percentage of your income that went to IT increased. A hospital employed doctor can be very successful, be paid a very fair wage, but in fact ultimately be under compensated compared to what they should have been paid based on their collections.
-I’ve got a job, I’ve got my numbers, I’m cruising.
Get to work on coding. I showed up at day one of my job and there were no other podiatrists there (which really, made me very happy). Thankfully, for the last 6 months of my residency I coded all of my office encounters. Every once in awhile I’d think – oh, I’ll just leave this one undone and my attending will sort it out. Guess what – that attending will be you soon. Get over to E&M University and start looking at the differences in new verse established, what is medical decision making, what are the most relevant modifiers (E&M verse procedural). My realization while reading it – I’m pretty sure I’m grossly over documenting. All of that horrible nailcare you hopefully won’t be doing - we’ve discussed this before on here – it’s a hassle and its highly regulated. There is nothing worse than not being paid for it if you already had to do it. Learn all the Q7,8,9. Learn the A,B,Cs. Learn who qualifies for calluses. Calluses pay more than nails. Go to the medicare online fee schedule search so you know what this crap actually pays.
Physician Fee Schedule Search
Select 2019, pricing information, pick single (1 code) or range HCPCS, specific locality, all modifiers, and then set the locality to your area (there’s a list). The HCPCS code is the CPT code ie. For range select 99212-99215 to see all the standard new and established E&M code values, 20550 to see a plantar fascial injection etc.
The other day I saw a new patient who I decided was a Q8. My receptionist comes to me and says we won’t be paid for the Q8 because she doesn’t have a cardiologist on file. She then explained to me that the patient has to have a doctor managing their systemic condition ie. The internist who manages their diabetes. I pulled out the guidance and showed her that the PAOD diagnoses do not have a “*” next to them and the asterisk indicates the patient requires someone else to manage their systemic problem. So jokingly, I spent 10 minutes arguing with my receptionist to justify a $35 charge. That said – highly regulated. Be like Natch – don’t learn the rules because you don’t offer the service. Or learn it because you’ll probably do more of it than you want.
-Additional things worth understanding – fracture care coding, globals, when E&Ms and CPT codes can both be used.
-What’s private practice like? Well, I would strongly recommend reading PADPMs thing at the top of the page. We work for our money. My practice only sees private insurance and Medicare. So the good news is we are probably receiving reimbursement that is about as good as it gets. In fact, some of the E&Ms and office procedures reimburse near the top of the fee schedule. That said – my patient volume is still low/growing and at the end of the day I sometimes count it out and think – I wish there had been a few more X-rays, a matrixectomy, a few injections etc. We don’t carry DME. We should but we don’t. The local DME store that gets my business keeps buying my staff milkshakes.
-Being in someone else’s office is an adjustment. The nurses are used to the other podiatrists and I’ve had to change a few “nurse educational speaches to patients” that aren’t in line with my recommendations. I STRONGLY recommend you bring with you or create educational materials to give your patient’s in line with what you already believe. My attendings had some sheets like this though after I made my own versions I comically realized they were rife with spelling errors.
-My new office does matrixectomy procedures as a sterile event – I definitely put a stop to that. They also only perform them ..twice a day at specific time points because it takes so long… I told the receptionist I don’t want an ingrown nail turned away that wants to come in. Will see if that comes back to bite me but I did 6 in one day awhile back out of a 11 patient day.
-I’m still not credentialed for surgery so I’m definitely discussing all manner of conservative care with people at present.
-Within 1 week of starting I was taken out for a steak dinner and then pitched a deal that I’m sure is a Stark Law violation.
-Coming back around to PADPM above again. I suspect it would probably be considered very poor form to tell you all what my E&Ms and CPTs pay, but again – they are good amounts and yet you would still have to pile a great deal of them together to get these big numbers people are talking about. I’m personally aiming for $400K in collections right now with hopes I can revise up in the future. I’m seeing 10 new patients a day right now and it is slowly creeping up with follow-ups. I want to get to 20. I personally feel like my office is barely open – if I told you when we stop and start you’d laugh. If you work 250 days a year you’d need $1600 in collections a day to reach 400K. Now multiply that number by your collections percentage and realize you need that number to be as big as possible if you want to make any money. Now realize what that number would have to be for you to be paid a hospital starting wage. That’s all for now.
