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FLAOrthoPT -> what are your thoughts (August 27, 2005 4:30:00 PM)

What are your thoughts of changing the model of outpatient from one clinic hiring PTs, to PTs all being subcontracted. That is, you market yourself, get your own patients, work when and how much and on what terms you want. The deal is someone owns the facility and they get a percentage of the profits or they pay you a strict fee per patient you see or you pay them to rent space basically. I personally think this is the future of outpatient PT. Where you market your individuality to the referring sources and you may have one pediatric specialist, one orthopedic specialist, one geriatric specialist, someone good with spine, someone good with peripheral joints, etc...similar to an orthopedic group. You can self refer within and have some power in numbers and recognition in numbers but have your own terms when working. Would you sign up to be in a place like this? What would you arrange? Just thought it would generate some discussion, I see good in this and no real harm, I think it is where we are heading as a profession in the outpatient arena. What do you think?

Ben Galin, MPT, OCS




SJBird55 -> Re: what are your thoughts (August 28, 2005 3:57:00 AM)

It might be a good idea. I think you'd have to consider the patient populations a little bit better though. From another listserve I'm on, I get the impression that pediatrics had very poor attendance (meaning lots of cancels and no shows). Also, if you toss pediatrics in the mix, that would probably mean you'd need to increase the size of the facility (which increases the lease cost) and would need to have specialized equipment just for pediatrics.

There would need to be something in place though that united the therapists, I would think. If one therapist had a bad reputation, would the reputation of that therapist be carried over to everyone else? I know with hair salons, a bad reputation of one hair dresser doesn't necessarily mean all of the hair dressers are terrible. I see the set up you are describing of being like a hair salon (business structurally).

The marketing strategy would need to be thought out. Marketing isn't a simple kind of thing. It is time consuming and ongoing.

Why not just have a business structure that is like physicians or lawyers? My sister-in-law is working with a company that specifically works with the various govt entities here in MI and provides the health insurance plans. She's in a cool place - she has her normal salary (which is about at a recent grad PT level) and then has bonuses based on new clientele AND bonuses based on new clientele for the people she manages AND she has the option to purchase stock to capture even more financially. She takes her clientele seriously and is very consumer-oriented.... her performance directly ties into her ability to capture more financially. You can see it in her attitude too, when she talks. I doubt if the business structure of her company would work in the rehab world, but wow... definitely some wonderful financial perks.

In my mind, I highly doubt if I'd set myself up in a subcontracted place. I'd worry about ethics and the legal aspects because we aren't really joined as one. Also, you didn't mention billers - who would be responsible for that and how would the decision be made in regard to who chose the billers? Who would have the authority to decide who was accepted to be subcontracted out? Who sets the fee schedules? I could work, I guess, depending on who owned the facility and to what degree that person creates the environment including policies and procedures.

Also, with subcontracting, I believe here in MI the one doing the subcontracting work is tossed into a higher tax bracket. I don't know if it would make more sense financially if the salary made wasn't substantially more than if just W-2'd. And, then of course, the subcontractors would also need to definitely have their own professional liability insurance (which doesn't have to happen in employee situations - PT's have a choice).

I don't think I'd consider being subcontracted out - might as well go into business for myself OR into a company that would allow me to take a risk and own some percentage of the company.




FLAOrthoPT -> Re: what are your thoughts (August 28, 2005 6:00:00 AM)

i am not agreeing or disadgreeing, just starting discourse. At least here in FLA you're WAY better off sub contracted with respect to taxes. The owner would have supply the biller, and collect and collect the difference from what you charge and what they bill. This is going on already. I know of a place in MD that is cash paying practice but all are sub contractees using the space, they get a percentage of the amouont they charge and the facility gets the other percentage for overhead etc...
but i woul dlike to hear everyone weigh in on this, because I really do feel it is the trend we are going towards..




SJBird55 -> Re: what are your thoughts (August 29, 2005 3:05:00 AM)

In MI, being 1099'd (I think that's the form number) puts you in a higher tax bracket and a higher amount of taxes are paid. Being self-employed almost doubles your taxes and we have to pay taxes quarterly. Also, being a subcontractor means you have to decide how you're going to take care of health benefits (if you want health benefits). There are some financial negatives to being self-employed... of course, it does matter what occupational field. I believe you can make a ton more money as a subcontractor in the business world compared to our health related services world.




FLAOrthoPT -> Re: what are your thoughts (August 29, 2005 3:57:00 AM)

guess things are different in FLA, but what ele is new. Here as a sub contractee I have the luxory of deducting almost everything I do (within the law). I paid close to 9% in taxes when all was said and done. Healthcare for younger healthier people without families is rather reasonable (90 bucks for health and dental through bc/bs ppo). So other than the specifics and semantics, my real question is would you rather be in control of your financial situation be being sub contracted rather than a staff employee.




SJBird55 -> Re: what are your thoughts (August 29, 2005 6:46:00 AM)

The way I make my decisions is to look at the pros and the cons. If overall I'd be happier and at least financially even as being an employee, maybe I'd consider it... but my head tells me with what you described it would probably be better to just own a clinic and take the full risk. Our family insurance (BCBS PPO) with no dental is WAY more expensive than $90/month... and there are no office visits covered.

You threw out an idea/question... but technically there will be specifics in any arrangement that would probably be more the determining factor than just the idea of "subcontracting."

Being an employee isn't all that bad - it depends on the organization, it depends on the politics, it depends on the professional freedoms allowed, it depends on control of one's schedule, it also depends on where one is in life - not everyone may be able to subcontract nor want that kind of responsibility. Just like not everyone wants to own a business.




ehanso -> Re: what are your thoughts (August 29, 2005 9:17:00 AM)

Would each therapist have their own provider number? That may make a difference on billing.
If you are expecting to treat Medicare patients, I beleive there are serious restrictions for subcontract services. Could each therapist just rent space and then be their own provider? There could still be a single billing area. This may pass the subcontracting test. Also check with the private practice section. I am sure someone has looked at this already. No sense in reinventing the wheel. Let me know what you find out. Ed




goodlooks58 -> Re: what are your thoughts (August 29, 2005 9:50:00 PM)

In Santa Monica, Ca a PT group has been doing this since 10 years. Here the PT owner decided to hire a PT from the local hospital and instead of giving him profit sharing he decided that a percentage of the income from the new hiree went for the overhead and rest was given to the new hiree. The new hiree brought with him 2 large referral sources. Also I see an ad for USPT in our PT journal. Is this the same?




FLAOrthoPT -> Re: what are your thoughts (August 30, 2005 4:32:00 AM)

similar, they do all the overhead, etc, and you get a salary and percentage. Sounds good in theory, I do not know all the details, all I know is that most around here seem to fail, so something is not going well.




matotoms -> Re: what are your thoughts (November 15, 2005 1:24:00 PM)

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matotoms -> Re: what are your thoughts (November 15, 2005 1:28:00 PM)

medicare has very specific rules governing this. you can have subs and they can market themselves and they can have their own provider number and reassign bennies to the clinic and take a 'salary' or some method of pay that is not 'fee splitting'. BUT, it is the clinic that has to ensure that the billing and record rules are followed and it is the clinic that will get hammered for any shenanigans.




SJBird55 -> Re: what are your thoughts (November 15, 2005 11:54:00 PM)

not really, mt... providers of care are held responsible for the CPT codes that they use. A provider's documentation has to correlate with the services provided. I'm not saying that the clinic wouldn't get hammered, but don't forget about the individual providers - they will also have consequences.




matotoms -> Re: what are your thoughts (November 16, 2005 2:42:00 AM)

yes really... the billing number determines the responsibility if i reassign bennies to your number you are the 'billing provider' as medicare calls it...im only the treating therapist or provider of care. its up to you to make sure i got my shiite together before you send out the bill.

in so many words the language states that the clinic is not to act soley as a collector for the contractor and assumes all responsibility for keeping records and following medicare rules/regs.

if i contract for you and i see 10 pattients at one time and put down on my billing form non group codes for all of them and you send it out under your number and it gets checked out....you are screwed. i may have some cupability, but you as the billing provider have zero excuses for the fraud/abuse. this is very very plainly written in the medicare manuals and on the application for provider numbers.




Sebastian Asselbergs -> Re: what are your thoughts (November 17, 2005 12:23:00 AM)

mt, in your eample, aren't you still considered in breach of your PT standards of practice? Here in Ontario, Canada, the registered, licensed PT is considered at all times responsible for any billing under his/her/ registration number, whether done by self or by a clinic for them. These standards are enforced by our regulatory body, the College of Physiotherapists of Ontario. There have been cases where the clinic made "mistakes" (sometimes wilfull fraud) when billing for their therapists - the PTs WERE held responsible for the billing "problem". Does not matter whether the clinic is PT owned or not. Should make many PTs check the actual billing practices of their place of subcontracting.... This is all separate from the insurance leaglities...




SJBird55 -> Re: what are your thoughts (November 17, 2005 12:40:00 AM)

mt... the clinic will end up having penalties and a repayment of inappropriate services and after that frequent audits but the professional provider also goes down. Do you really think that the clinic would assume ALL responsibility? Think again... professional providers are fined or hauled away for fraud. Whether the provider is contracted or not, the provider does have a license and it is illegal to perform fraudulent activity. The provider of care would get sued by the clinic for fraudulent activity... Don't think that a provider of care only has to follow Medicare rules and regs - there is a such thing as the state practice act and there are laws against fraud.




matotoms -> Re: what are your thoughts (November 17, 2005 5:04:00 AM)

maybe the treating provider goes down due to practice act issues or conspiracy...but definately the billing provider goes down b/c they are the ones who got the check written to them. Medicare is not that sophisticated where they would go in and look at who the treating provider was...particularly in a CORF where not everyone needs their own billing number. Medicare looks at who they wrote the check to, and if they wrote a check to xyz corp for services that should not have been covered then XYZ corp is in a heap of shiite.

i dont mean to hijack this into a medicare rules/regs piece, altho when it comes to PT medicare is the biggest payor with the stiffest penalties for crossing them. Hell who even knows the policies of the HMO and PPOs other than you get this many visits. Medicare has very specific written rules and my only point, getting back to the topic of contracting, is that FOR MEDICARE...they do not allow the clinic to be used soley as the billing entity for all the contractors. the clinic would have ultimate responsibility/culpability in compliance matters, and would henceforth be screwed if issues of impropriety surfaced. This is plainly written in the manual.

tho i will agree that employees / contractors who perpetuate fraud may also be at risk.

also keep in mind that pretty much the only way medicare polices billing providers post payment is thru private lawsuits. yes they have software that checks CCI edits and all that crap prior to paying, but as far as post payment they rely on 'rats '. every so often they will do mass reviews ala 1997 ish where rehab agencies got hammered everywhere, and we are likely due for some more of that.....but otherwise its qui tam lawsuits that find the cheats, and they go after the money ..... the plaintiff is encouraged to rat out the cheats by taking a % of recovered monies...and its the billing provider with the money. BTW..i love rats.

hows that?




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