Recently we had a student ask a question of us that we thought might be of interest to you as well. So jump in and share your experience or thoughts concerning the following!

"What information do I need to consider before opening and running a "cash" practice?

Here are a few words of wisdom and caution we have elicited so far,

"A cash practice depends on the economics of the area you choose to practice in and the benefits available to the patient."

"The best advice you could receive is to find yourself a reputable tax accountant or CPA who will help you set up ethical accounting practices."

"New practitioners may fall prey to "cash box" living, pulling $20-$30 dollars from the till to pay for lunch and then not accounting for it when the time comes to pay the bills."

"Will the D.C. refuse Medicare patients then? If they don't, they can be required to submit insurance forms."

"Remember, when patients have insurance, they tend to stay within the parameters of their company's rules to maximize benefits. They are given a book of providers that they may visit for little or no outlay of their own money. If you are a "cash only" practice, you will not be listed in the book of providers which may slow business growth."

"Inform your patients when they make appointments with you that you ONLY accept cash, credit and debit cards. Reinforce this policy with a placard at your front desk. Then get a credit card processing machine, (NCMIC offers this product) for the ease of the patient and prompt payment."

"The most successful practices, cash or otherwise, are the practices where the doctor listens to, educates and cares about...the patient. Then the patient is quick to refer and referrals build business."

I had a great question the other day from the Ask The Expert feature on www.startingintopractice.com.

The question was from a doctor who is in an associateship, but is planning on opening a practice in another state.  His wife is from the other state so they are moving home, in a way.

His question:  Which comes first...securing financing or securing a location and lease?

The answer:  Neither and both.  These two pieces need to occur in tandem.

The problem is that the lender likely will not close on financing until space is secured AND a landlord likely won’t close a deal for a lease until financing is in place.  So, both these issues need to be dealt with in at the same time.

A great first step for this doctor is to contact a commercial real estate agent in his target community.  They will be able to provide a great deal of information on what is available in the market.  If his wife is from that community, he may be able to tap into her network of friends and family to get a good referral.

Once he gets an agent, they will be able to provide estimated costs and available properties in the area.  From there the search can be narrowed down to a limited number of properties based on demographics, who he wants to serve, where he wants to be in the community, etc.  Now he has a better idea of costs to plug into the business plan and start talking with lenders.

Talking with lenders is another process that will take some time.  Again, tap into any networks available through contacts in the community.  Then start shopping the business plan around.  Once he finds a lender that will work with him, the ball will start rolling.  Now he can negotiate the final lease and negotiate the final terms of the financing.  Again, this will likely happen at or around the same time.

One more thing.  Anytime doctors are dealing with leases and contracts, a review by a local attorney is in order.  Again, it is best to look for referrals to find one.  The attorney will be able to give advice on the contracts needed for office space and financing.  The review of these contracts will cost a little bit of money (typically $200-$300) but will save you much more by preventing a mistake.

Quite a process and no two doctors' experience are the same.  The key is finding good people to provide advice and guidance and working through the process in a well planned and thoughtful manner.

I get a lot of questions from recent and soon-to-be graduates.  One common question I've been getting a lot of lately is about Medicare.

Can I opt out of Medicare or can I just not accept Medicare patients?

I am not an expert on Medicare.  Fortunately, though, Dr. Mario Fucinari, one of our bloggers is.

He addressed this issue last summer and I think it is an issue worthy of a revisit.  So check out Dr. Fucinari's blog here and feel free to submit comments with your specific questions.

Following are some questions recently posed through "Ask the Expert" on this site. You'll see the answers posted to each section. I hope this helps all our new D.C.s.

I’ve heard that a successful practice can be measured by (1) new patients, (2) case average/dollar amount and (3) patient visit average. I understand the first two but am perplexed about the third. In all I have studied, there is a huge range of recommendations for care. I've seen ranges from 3-7 visits over a few weeks to 50-100 visits over a year. 

These are not the successful numbers.  New patients definitely are the lifeblood of any practice - new or established.  So getting NEW patients is critical at any time in the practice cycle.

There is no case average. The case average is not established before you start seeing patients but rather after you have been in practice for some time and understand the “case mix” of  your practice, the demographics, the practice style you have opted for, and a host of other factors such as size of facility, number of treatment rooms, staff, etc.

So the average after your first year and second year will be determined by your practice and not some outside number.

The Patient visit average….is simply bogus practice management guru talk. The patient visit average is whatever will get the patient to a functioning state.  Nothing more. Nothing less.
 
It is this very absurd number of 50 to 100 that has gotten this profession in trouble over the years.  There are very few cases which will ever require that kind of number of visits, much less to call it an “average.”

What do you find most docs do for recommendations for care? Do they follow certain guidelines or protocols or documents?

You should be thankful that your college taught “ethical” management of patients and the recommendation for care is what you can justify and document coupled with demonstrable evidence of improved outcomes.  The care is individualized and not based on any average but on each individual who walks into your office.  We are not dealing with widgets … but with people who are scared, suffering and vulnerable. They need to be treated as such.
 
From the outdated Mercy Document to the AHCPR Document to the more recent Council  on Chiropractic Guidelines and Practice Parameters (CCGPP) which have just recently been published … these will provide the most evidence-based protocols and guidelines available. 

Is there a case for "maintenance care" or "supportive care"?   If so, how do we get that across to our patients and get them on board? 

Certainly there is a case for maintenance and/or supportive care – but these are two very different items.  Maintenance is care that the patient selects without any health condition and is paid for by the patient out of pocket. There are no insurance company plans that pay for maintenance care. It is desirable and when the patients self-select this kind of care they are excellent patients and very compliant and health conscious.  Supportive care is care that is therapeutically necessary because the patient will not be able to sustain maximum therapeutic benefit when care is withdrawn. If you are able to documented it, then it should be reimbursed.

I also would like some numbers. If someone comes in with back pain or neck pain, what would the average chiro recommend for treatment in visits and time (weeks)? What would he/she do once the patient is out of pain? Drop them from care?   Continue to treat them until the treatment plan is done? Is there justification for treatment beyond pain? Who or where would you recommend I turn to for more mentoring on this subject?

Easy ...  take the time to educate them.  And recognize early on that not every patient will buy into that model.  Accept it, covet those patients and take time to develop the kind of practice you want.
 
Examine the patient, determine the history, do a physical, conduct appropriate testing, put the patient on a two-week minimum of care and re-evaluate. The rule of thumb is if a patient is not demonstrating some improvement in a two week period, it should raise red flags with you because something is wrong. If you work in two week intervals, there is always time to reevaluate your options based upon the patient results and there is no long-term commitment, the commitment is based upon patient outcome and doctor patient relationship (the best kind).
 
Physician know thyself …you are already on the right road by not adopting the nonsense that has been touted in the chiropractic press. You obviously are uneasy with long-term care with numbers that are picked from the air.  Deal with each patient as an individual and you will not have problems being successful and getting your patients, better quicker and less expensive which is the very thing that made chiropractic great.
 

Recently, we received a question from a D.C. about announcing an office opening. The doctor was considering including an offer of a free consultation and exam and wondered if this was a common practice, how to handle billing, etc.

Beware of what you read in a marketing magazine article or book or learn in a practice management seminar.  Although the author may have good intentions, they may not be aware of compliance issues and the law. 

As a Certified Compliance Specialist (MCS-P), I continue to see violations of the Anti-Kickback Statute. 

Simply stated, it is illegal to offer free services or inducements to Medicare, Medicaid or Champus. Furthermore, certain states, IPAs and PPOs do not allow any offer of free services.

The anti-kickback statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Where remuneration is paid purposefully to induce or reward referrals of items or services payable by a Federal health care program, the anti-kickback statute is violated.

By its terms, the statute ascribes criminal liability to parties on both sides of an impermissible "kickback" transaction. For purposes of the anti-kickback statute, "remuneration" includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind.

The statute has been interpreted to cover any arrangement where one purpose of the remuneration was to obtain money for the referral of services or to induce further referrals. Violation of the statute constitutes a felony punishable by a maximum fine of $25,000, imprisonment up to five years, or both.

Conviction will also lead to automatic exclusion from Federal health care programs,including Medicare and Medicaid. The OIG has previously taken the position that "incentives that are only nominal in value are prohibited by the statute," and has interpreted "nominal value to be no more than $10 per item, AND no more than $50 in the aggregate on an annual basis."  

This means that you cannot offer anything of value for free or other than fair market value unless it is $10 or less and no more than five times per year.

Dr. Fucinari is practices full-time in Decatur, IL. In addition, he is a part-time instructor at Logan College of Chiropractic. He has earned the designations of Certified Chiropractic Sports Physician (C.C.S.P.), Certified Insurance Consultant, Certified Medical Compliance Specialist (MCS-P) and Certified Medical Compliance Instructor (MCS-I).

Here's a question I received from a recent graduate. I'm sure this idea has occurred to several of you.

Hello Dr. Fucinari, I'm currently looking for an office space to work out of.  I already have a couple of people who want to be seen, so is it possible to see someone in your living room and stay within HIPAA guidelines?   

 

I know it’s somewhat less than professional, but until I get a good deal, I'd like to start building a reputation.  I was curious about the legalities of seeing someone in your home?  I’m assuming it would be like a house call?  Since I haven’t formed a business, would that default to a sole proprietorship regarding liability?

There are several things to consider in this situation.

Since you are in your own home, it may not be such a big deal for HIPAA.  You are not a covered entity unless you file claims or check other information electronically.  All files have to be protected from unauthorized disclosure, theft and fire. 

The BIG problem comes with liability. 

Let’s have others weigh in from NCMIC as to liability.  You have a huge liability in case someone falls at your home. 

You should check with your homeowner's (or renter's) policy to see what coverage you have. 

When I graduated from college and began the process of job hunting, I made a crucial mistake.

I was talking to different prospective employers, using the interview skills I had been developing, impressing the interviewers with my stellar academic record and winning personality...well, something like that at any rate.

Some of the employers actually did like me though and we started talking money.  I ended up taking the first offer that came along because it sounded good.  But was it? 

How would I know?  I didn't do my research and homework.  I did not have a personal budget so I didn't know how much I needed to take home to live.  I didn't research cost of living and average salaries for my area.  I went into the negotiations blind and accepted the first offer that came along because it sounded good and I was desparate.

I think some of the chiropractic students I talk to are heading into the same mistake.

When you are interviewing, looking at space for your own practice, or talking to docs about independent contractor relationships, you need to have a firm grasp on your personal budget so you know where you need to be money-wise on a monthly basis.  It is the best way to tell the good from the bad from the "not great, but let's negotiate".

It's also helpful to know what is happening in the marketplace.  Just this week, Chiropractic Economics came out with the 11th Annual Salary & Expense Survey.  This is a great tool to help you get a handle on the numbers.

Bottom line...this is your career.  You need to make smart decisions every step of the way. 

One thing it seems Hollywood stars get wrong more often than right is finding the right match.  The celeb divorce rate is off the charts.  We, the viewing public, are subjected to poor casting and rotten scripts resulting in dismal performances (need I bring up "Gigli" or any of Jim Carey's dramatic roles?).  And we are tantalized by on-set feuds between actors, directors, producers, you name it.

And finding the right fit is someting we all struggle with.  The right fit can mean the difference between a positive, life-changing experience and a miserable, destructive relationship both for you and the other parties involved.

The question that got me on this topic is a common one I hear from students across the country:  "Where do I find an associateship or buy-in opportunity?"

The simple answer to that is found under the resources section of StartingIntoPractice.com.  We've included the classified listings from all the colleges and it's about the best resource to see what opportunities are available.

But finding the opportunity is only half the battle.  Much due diligence is needed on your part to make sure it is a good fit.  The feeling you have after meeting the doc and visiting the practice will be huge.  But you also need to make sure the proposed contract is a win-win for both parties.  Some tips to help:

• Have your own legal representation to review any contract and advise you.
• Understand your personal budget so you know where the compensation needs to be for you to live.
• Network within the community and with other chiropractors in the area to determine the reputation of the practice and the doctor you may be working with.
• Don't sign anything you don't understand.
• Don't sign anything you don't intend to comply with.

So when you are looking for a good match, do your homework.  Poor matches are expensive and can stay with you for a long time....just look at Mariah Carey in "Glitter."

I was at one of the chiropractic colleges last week and had a great conversation with a student well on her way with her planning process.

She validated something I've been preaching for years.  I love it when I'm right!

This student had recently attended a seminar put on by SCORE.  SCORE is a non-profit organization designed to help businesses succeed.  Its volunteers are seasoned business people who are donating their time, talent and experience to help you get going on your business goals.  They have offices and chapters all over the country.

This student was RAVING about her experience.  She said the seminar was informative, cheap, and educated her about all the resources that are available to her, either through SCORE or other low-cost or free sources.

But probably the most important thing she got out of the experience was the message that she can do it.  She is now confident she will be able to start a chiropractic practice and succeed! 

SCORE is a great organization and just one of the many sources available.  NCMIC has a wealth of information available to you on this site and have links to many other resources under the Tools and Resources tab.