• LecturehallLIFE SKILLS: Finance For Physicians ... Everything from Contracts, Leases, Etc
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Male Speaker: Next physician that we have speaking Dr. Hrywnak, I hope I pronounce that correctly, thumbs up, good. Dr. Hrywnak is a graduate of University of Buffalo, degrees in molecular biology, physiology and electrical engineering, also graduate of Scholl Podiatric Medicine 1982 and then 1984 MD degree. He teaches practice management, business law and is a clinical professor at Northwestern School of Medicine, department of family practice. So please welcome Dr. Hrywnak.


    Dr. Hrywnak: Thank you very much doctor. The reason I'm running around here limping is I'm 16 days post patellar fracture. How am I doing? Not bad. Okay. Today's topic is one that a lot of people do not what they hear about but guess what once you finish your residency or your fellowship, it's something you're going to have to deal with and dealing with the profession called attorneys. So we're going to talk about here in the next 30 minutes is going much information as possible, you're going to deal with attorneys, contract law when you're applying for position that I don't care if it's for buying out of practice, I don't care if it's joining a multispecialty group, whatever reasons, even in academics, we're going to talk about the basics here. So again, I have no financial relationships or conflicts of interest of the upcoming presentation. Some of the objectives here we're going to try to cover in 30 minutes, all the highlights regarding contract law. Again, a contract is an agreement between parties, especially one enforceable by law. There's many types of contracts; unilateral, bilateral, quasi contracts, voidable contracts, nonvoidable contracts but what is particular to every single contract that's written out there being verbal or nonverbal is the following.

    A contract must have an offer, must have acceptance, must have consideration and consideration is usually in the form of money 90% of the time. It has before legal purpose and the parties have to competent enough to understand what they are signing. That's basic in any contract. But one thing is to remember when you go forward and look at contracts that you see in the bottom there, the big prints give it, the small prints take it away. Alright. Always remember that and everything is written in legal lease. Now back in 1967, very few of you will remember this but they try to pass a law that all contracts have to be written in layman's terminology so anybody can pick it up and understand and that got defeated solemnly because that would put a lot of attorneys out of work, so that's why contracts are written in legally for specific purpose. Contracts when you get for employment are all going to deal -- going to have various clauses in the contract and you have to get familiar with it. There is no such things as a standard contract with somebody tells you what I'm giving you here is a standard contract that everybody signs this. Absolutely wrong. Never buy that premise. All contracts are different. All contracts are unique and all contracts are what? All contracts are negotiable. I don't care if it's the sales contract. I don't care if it's the employment contract. Contract is an agreement and the tool to that agreement is negotiations. So you really should know what you need and what you want. In the last two years, I've been spending doing two things. I'm on health economics tour lecturing because I do analytic analysis of profession and what their future holds. This is the first thing I've been doing in the last two years and if you're from Illinois the last two years what I've been doing on this working to get a fully license for doctors of podiatric medicine in the state of Illinois. The reason being based on the economics and based on the analytics going forward of what I see podiatry to be successful going forward, you need to have a full license. So that's what I've been working on very hard. I'm on the Board of Illinois Podiatric Medical Association and we have been doing a lot of hard work to get a full license for doctors of podiatric medicine.

    This is a topic for another time but due to the increase in PAs, physician assistants or nurse practitioners, and population of health management to be involved in the healthcare going forward the past 20, 21, 22, you should have a full license if you want to be included. That being said, the contracts are all going to have the following basis to them from preamble all the way down to exhibits. It's always good to have an attorney review a contract but you as doctors you have to get the understanding is you make the final decision of what you add in the contract not the attorneys. Attorneys make money by reviewing contracts and your attorney might not like what the other attorney has proposed and it goes back and forth and the hourly rate goes up. And nobody wants to pay somebody $375 an hour to read. You read the contract, you question the attorney on the parts on the contract that you don't understand and after that, you decide what you want in there. Keep that in mind. It's all negotiable and nothing is in concrete terms yet. The typical physician contract, number one is the compensation and benefits and any provisions for partnerships, your professional obligation. Another important thing is termination and restricted covenant. Now, why do I say termination is the most important. I always had ex-students, they tell me, oh, I just sign a three-year contract and I'm going to be an associate or lock into this partnership. I'm buying in, etc, etc. So I ask them one question, what's the termination clause. Well, the termination clause says that either party can let the other party go off with a 30-day notice. You don't have a 3-year contract. You have a 30-day contract. So termination clause is the most important part any professional doctor's agreement. The second is restricted covenant, we will talk about that. Compensation and benefits. And these are the current statistics being used going forward is a doctor who is going into practice with somebody else or going into group is going to get a base salary. All these contracts that I've seen in the last few years and believe me I've reviewed over 1500 contracts in the last 20 years from especially podiatric medical students and regular medical students and I've seen every trick in the trade.


    And the thing I always tell people is they get disgusted, look at the contract I've gotten. This can't be right. I always say just relax because in 10 years when you're going to take it to associate or a partner, you're going to want the same thing. You're going to protect the asset you built up. So let's work for you how to get that asset, how to become a partner or how to maintain and keep employment. So once you have that base salary, your bonuses are going to be based on a compensation formula that's a percentage of what you collected. So usually, a contracts now -- the ones I've seen the last two years start between 75 and 110 and they have a 20% to 25% bonus after you've achieved so much in collection. The amount you receive in collection is usually based on what your salary was. So if your salary was 75,000, pretty much so the senior doctor in the group is going to say, you will get 20% after you collected a 150,000. So one and half to two times the rate. So you're going to pay for yourself, make the business a little bit more money and then your compensation starts to kick in. It's always safe to look for a contract. This is what happens lately with the economic trying to get something that covers your expenses. Bottom line, you have to do your homework. Don't accept anything that's out there because you need a job. I have a surgery center, I look at calls from graduate saying I didn't get a job, I will come work for you for free. No, you're a doctor, you're not going to come work for me for free. Don't devalue yourself. Your value is at least $275 to $325 an hour post residency. So don't sell it for something just to have a job. Now, base salary incentives is what mostly everybody uses. There is gross billings and there is net collections. Some contracts will give you a percentage on the gross billings which if you find one of those, god bless you. Most of it's based on what you've collected. Another important issue, when you're in a bonus system, you need to get a copy of the EOMBs, explanation of medical benefits. Remember, somebody is billing for you. You want to keep an eye on what your income was, what your production was.

    The only way to do that is every quarter when you're going to get your bonus, you get a copy of the EOMB for all the patients you saw and you have to calculate. Now, the senior doctor of the group doesn't want to provide that to you, that should raise a question mark. It's your patient, you're getting a percentage, you need to see what they bill and what they collected. You can't go by what they said. And also do not sign blank forms. We just had a case few years ago. A young lady graduated a podiatric residency. She was up in Seattle, a satellite clinic. The satellite clinic was 47 miles away from the main office. So the doctor said you sign all these Medicare forms, I had a time enough to go back and forth to the office. She signed maybe a 100 Medicare forms blank. They filled it in that she did all these procedures. She lost her Medicare privileges because what they put out in there was never done by the doctor and again you can't claim ignorance. You're a doctor. You can't be signing blank forms. So again take all these precautions into mind. It's a tough world out there. Factors that influence the salary offer. You have to be happy of what you're going to get, where you're going to be located. Are you going to be there forever or is this just a pit stop on the way to the future home or the city that you wanted to work to. Most residents when they finish, they try to find a job some place instead of somewhere they want to be and that causes a lot of heartache. You don't want to go to a place that you know you're never going to live in but guess what for just getting a job, they are going to do it and that's just hurt you down the road financially because you're never going to set foot where you want to be. So you have to do your research. If you don't do your research one month till you finish your residency, you do your research during the whole three years while you're resident to see where you want to go or where you want to wind up. You start making those contacts to those doctors down the road. So here in Chicago if I want to wind up in Indianapolis, I'm not going to wait till one month till I finish my residency, I am going to be going on weekends to Indianapolis to see what doctors are out there, to see who is looking for associate or future partner or to get in to a group. Last minute usually doesn't work. Last minute turns out, I just took what I can get because I need the money and that's usually not enough.

    Again, we talked about this billing overhead, the range is from 35% to 65%. It varies. Collections are different from gross billings. Had you had any practice management experience, I might bill a 100, the insurance might pay me 60. The prevailing standard which I fight all the time is insurance companies now Aetna, United, Humana, LeasingDesk, their foundation is what healthcare corporation for the reimbursement. Anybody know who is the foundation -- where they base it at? Medicare. They base it on Medicare. Any percentage of Medicare. So going forward, everything is going to be getting 80%, 90%, 10%, 110%, 120% of the prevailing Medicare rate in your area. I'm not one that's favor of that. From the economic standpoint, you can't go by Medicare because of the consumer cost of living factors in that geographic area, but that's what they go by. So it can be insulted. The worst insurance out there now, anybody know? Medicare Advantage. Medicare Advantage promises the senior everything under the sun, why? They can promise them everything under the sun but pay the doctors virtually nothing because they will pre-certify what you want to do but then not pay you and that's been going on like crazy. Now by 2023, they want to have at least 60% of the US Medicare population enrolled in the Medicare Advantage program. Medicare decided that we don't want to rub it any more and we're going to give it to all these different companies. The companies make their money based on the administration fee. What they don't pay the doctor, they get to keep themselves. That's the bottom line how it works. So we have to understand that when you're negotiating. You want to get an insurance profile of that practice of that group. Are you 30% Medicare, 30% BlueCross, 30% other. Are you 70% Medicaid, that's going to make a difference in your reimbursement. Remember, we're shifting. We're shifting from fee for service to bundle payments to value based reimbursement. The days that the more the doctor does, the more he or she will get paid are slowly drifting away. Things are changing. Not in front of you because you're busy doctors, you're busy residents but behind the scenes as I travel around and see what's going on here, it's getting more evident and evident.

    Just 10 years ago, there were 72 areas for billing, centers for billing in the United States, 72. So it's all regional. I'd send my Medicare bill or my insurance bill to something in local area. Now, we're down to six. So you see what's going on here. With the computers, with the analytics going on here, we're down to six billing regions now. Pretty much everybody sees what everybody else is paying and that's what's going to be the reimbursement to you as a doctor. Here is the same example again. You have to work twice as hard to make up for your salary, be careful with that. Lot of doctors get away with that. The other thing for you guys out there, you docs, be careful is incentive-laden contracts. I get enough of those. I see incentive-laden, meaning, you have to perform 15 soft tissue procedures per quarter, you have to dispense 25 orthotics per quarter. If you fail to meet the quotas, then they can terminate you immediately. That's without cause. Be careful in incentive-laden contracts. That's not fair to you and we have to question ethically what's going on here. Again, other ways, bonuses can be determined, number of patients, patient satisfaction, your referrals, academics. It's basically what your production rate is. Whatever you produce, you're going to get a percentage later down the road. That's the number one way reimbursement as a bonus for you as a doctor is calculated. Again it's fair for both you and the employer, the harder you work, the more you should get. And of course, do not be an associate. Can't sign an associate contract without knowing that you have a chance to become a partner in the practice. You're just delaying reality. So I always tell students, the DR in front of your name could stand for doctor as an abbreviation or it can stand for DR, delaying reality. If you're not going to get a piece of the pie down the road here, you're just wasting your time. But you would be surprised how many students post residency will grab a job anywhere just to have income doesn't do you satisfaction, especially if you have a family. You have to pick and choose ahead of time where and what you want to do.

    Other income, other traps that I see in contracts. You, as an associate, are going to get extra amount of dollars as base. You're going to get extra amount of dollars as a percentage of what's collected. Also, it will be buried in there the small print that any other type of employment you do while you're an associate comes to the head doctor. So if you have a nursing home on the side, all the money comes in. If you're going to bag groceries or jewel, guess what all that money you make at jewel bag and groceries comes to the head doctor. So watch out for those kind of traps where they could grab other income from whatever you do. I don't know why but there is more and more contracts like that that any other derived income outside this practice all belong to the main practice. Academic salaries are going to vary little bit differently if you're going to get a job at a university or a teaching center. Those contracts are written differently. Those contracts and lot more contracts will be written based on relative value units, RVUS. I gave you a handout and you can read through it to understand how RVUs are calculated. It's usually a lecture on itself and takes about an hour to explain how RVUs are calculated because your productivity is going to be measured in RVUs and that's going to turn into your income. The best contract I saw in the last six months was a young lady finishing a podiatric residency. She got a job in California at hospital starting salary 400,000 a year, right out of residency. Contract was 26 pages long. Toward the end of the contract, it's said if she doesn't meet the RVUs for the current year she is employed, she has to give the money back. If you do the calculation, there is no way she is going to see over 1600 patients a month. So what was good if she got 400,000 this year and 75,000 next year because they have the right on the contract to take it back. You have to be careful. Hospitals aren't dumb. They are very smart. They have good lawyers negotiating contracts. And believe it or not here in this day and age, there is always a doctor; family practitioner, internist, podiatric physician calling the local hospital to say please buy my practice, please buy my practice and they know which practices to buy.

    Plus a lot of podiatry groups are buying practices to make a big super group in order to get better contracts. That's a discussion for another time. What else you want in your contract? Usually, it works like this, the more money you get per year as a salary, as an associate starting out, the more money you get, the less will be covered. Meaning I'm going to give you 110,000 but you get your own malpractice. You get your own health insurance. You take care of your own CMEs. Then, there is the other ways which most of you get 75, 80000, you're getting that but the office will cover malpractice insurance, will cover a health insurance and any other insurance that you might need, that's what going on back and forth here. Most contracts that I've seen lately, it's a lower salary and will include everything, which is the way it should be the right way if you want to have associate leading to a partnership. Again, retirement plans, that's a little bit different. If you're going to become a partner and your associate agreement or in your group agreement if you become a partner in a big large group, somewhere in the contract, if it's a two-year contract, somewhere in the contract you have to state that while I'm an employee of this group, we have the right to go into negotiations in order to buy into the practice. This way, you know if you have a shot for buying in. Now, if it's a successful practice and the doctors have established a great relationship with the bank they work at, they should be able to give you last three years income tax returns, send them to their bank and say he is buying in or she is buying in 20% or 30% of this practice. It should be automatically. You will have no problems getting in. You just can't wait till another two years to say, you know what, it didn't work out. Here is all these numbers but we want a million dollars for the practice which you know is not right but you have no recourse. So on a two-year contract about a year and year and half, you want to start negotiating. The other problem I've noticed lately is when the doctors do give their income tax return for the business for the past three years, it has only happened twice in the last couple of years but that's twice too many times. The doctor would wide out their income tax return and put in the income a lot higher.

    So if you're going to buy my practice or if you're going to buy in, the numbers are wrong. So you've to get a verification form. It's D161 from the IRS. They sign and you will get actual and true copy of the business. I hate to say it but you can't trust everybody of the business's tax return so you're not buying in any false number. That happened twice already. So you got to be careful on that. If you're buying a practice, the average right now is 52% of the gross. Now, I know a lot of the doctors won the 100% of the gross, it doesn't work like that. And that 52% was 54 a year ago. So you see where it's going. So if you buy into a practice, it's a percentage of the gross. You're buying the equipment, you're buying the goodwill, the goodwill stands for the patient's chart. Just keep that in mind. Other benefits that you want in your contract, again becoming an associate going into partnership, going to super group whatever. These are things you have to encounter and think about it, it's very important. Again, as we mentioned, things that get covered, promotion basically deals with those, that we are going to get into. Academics, partnership requirement. Again, things are shifting. You got to be very careful and you're always more than welcome to call me if you have a question of what's going on. Reimbursement is changing day by day. That's the one constant. The constant is changed. So what you need to be aware of is what the doctor says we're not making as much money this year as we did last year. He or she are telling you probably the truth because things have changed that much in a dramatic fashion. Now, everybody here you don't want to hear my lecture on analytics medicine. You think it's all going to be surgery. Well, let me tell you within two years, they are going to be denying surgeries of any type left and right because that's in their plan. Understand that's why you got electronic medical records eight years ago. That's why x-rays have to be digital now, so the digital x-rays can be sent by email to somebody that's reviewing the chart in another state whose background is ob-gyn but they are going to be reviewing your foot case to see if you really need to do surgery, that's going to increase, that's on the uptick greatly.

    So you got to keep that in mind. It's not always going to be about surgery. I know people wanted to do surgery and think it's great. If you really do the cost, amortize it over two years what you're making, you are better off seeing general podiatry patients all day long than doing the surgical patients. As an economist too, my axiom is when you leave your office, you're losing money. Okay? And again side steps here what you can bring to a practice. Not everything is going to hospital based. There will be a lot more hospital closing going down the future. You have to understand that the successful practitioners are those who can do surgery where? Not in the hospital, not at the surgery center but in their office because when bundle payments coming into vogue and they've, interventional radiologists are already in bundle payments. They are doing vein stripping not at the hospital, not at the surgery center, in their office and the bundle payment to the doctor is $7200. You think that's a lot of money versus $38000 if it was done in the hospital. And as they change the Stark law, you get the 7200, you get the anesthesiologist that came to your office 200, the rest is for yourself for 300. That's where it's all going. I know a lot of doctors don't like to hear that but guess what those who hear and listen to it are doing more and more in the office. At the orthopedic meeting last week here in Chicago, American Orthopedic Foot and Ankle society, they were advertising and pushing how to set up your office for ankle and knee and shoulder arthroscopy because they are getting ready for bundle payments, they are getting ready for value based reimbursement. That's what we should be doing. That was a little side step to kind of give yourself, again you are going to be physicians but guess what you still have bills to pay. So you want to maximize the way you're going to drive your income and keep your patients happy. Specifics on partnerships, again, you got to know how much they want, what's the time to buy in and you should be fine. Partnerships are safe haven, that's what you want to be. You want to become a partner. Now, everybody says I want to work for an orthopedic group. I see a lot of contracts from orthopedic group that hire a podiatric physician surgeon, but what are they buying.

    The highest I've seen in the last two years is 12% of the orthopedic in practice. So you do not have a vote. You're not in control of any decision. You actually own the part of practice but it's 12%, 8%, 6%, that's what going at. What you have to keep in mind is changes are going to happen to all major groups going forward regarding physician assistant and nurse practitioners. Insurance companies are pushing behind the scenes in Washington to have those to be primary care leaders. 32,000 nurse practitioners graduated in June. 26,000 physician assistants graduated in June. The government has already allowed another 16 schools for nurse practitioners, another 30 schools for physician assistants to be opened in the next two years. They are driving the boat. They see what's going on here. So when I talk about changes that are happening, you got to adjust. The best surgeons in my book are the ones that can cut out EGO from the word surgeon. You can cut out EGO, you're going to be successful. If you don't cut out EGO, you're going to be one standing there waiting for the next frame to come into walk into your office. They are going to call you from the ER. It's Medicaid patient, you're going to make $6.10. But it's satisfied your EGO that you did this case. Who loves this lecture more than the doctors and doctor's spouse. Tell my husband, tell my husband. He runs to the hospital. He is there three hours. He does that one case. Stop and think. That's ego gratification or you're trying to make an income. If you want to walk around with the coffee cup in your scrubs and tell everybody you got this case coming up in two minutes, god bless you. But the best surgeon is the one that did the case and ran from the hospital back because there is patients waiting, not strolling the hospital. But these are just little things to curb ego of lot of residents because you get all pumped up and you want to do all these great things but the reality that hits you and guess what you might do C&C, you might do nails, you might do things that you never thought you would do before but it pays the bills and better yet makes the patient happy come back to you. Restricted covenants. All contracts have restricted covenants. Restricted covenant meaning that if you decide to leave that practice, you can't practice for so many miles and so many months within the main office.

    Now, the FTA ruled on this back in 2004 because a bunch of cardiologist quit a hospital in Nashville, Tennessee and they opened up a few blocks from the hospital. The hospital sued. You have a five-year five-mile restricted covenant. You can't be within this hospital area for five years. They sued, they went to the FTC, Federal Trade Commission and they ruled you're right, you can't. At that time, they said what's most fair to hold up in court is two years two miles. I've seen contracts especially for residents who just finished podiatry, you can't practice in the county. If you quit, you can't practice in the state, illegal. You can't deprive somebody from making an income. The next step that's going on with the changes in the healthcare is you want to eliminate the restricted covenants. So if you quit, you want to open up across the street, you might be able to. So right now, the fair amount and the restricted covenant is two years two miles. The doctor might ask you, hey, I want five years, five miles walkaway. The other trick of the trade is two years, two miles within any existing office. So the doctor has one downtown and has a satellite office in the suburb another one. Guess what, you just put yourself out of the county because it's two years of any existing offices of that company. So you have to be careful of little tricks of trade like that [indecipherable] [0:25:19]. Now you could say what are they going to do to me if I open up 1.9 miles away. With 1.9 miles, they are not going to do anything. But if you do open up close, the other doctor has to put up bond that cost a lot of money to prevent you from practicing that close. So do they want to go into legal battle? My axiom again dealing with lawyers is following. Settle, settle with anybody that you're going to sue or somebody is going to sue you. You enrich lawyers by going to court. A successful attorney is a poor attorney, meaning they can solve your case within a day or two. That's not how we operate. Abraham Lincoln said we have to bill for our words because that's all we have.

    So if I'm thinking about you in the shower or in the car, I get to the office I write down. I thought about you for 10 minutes about your case, 200 bucks, legal and legitimate. So the axiom is right or wrong, how much do you want to spend to prove you're right at the court. Don't do it. Settle, you will be far ahead, whole 9 yards. As far as malpractice is concerned, you always have to be careful with your malpractice attorney. They are not your attorney. They work for the malpractice insurance company. They are going to want to settle it quick, but what do you have to admit to in court is what you have to find out, why are they giving away because they not only to fight it but they are also going to try to settle it as soon as possible because that's money out of the pocket. If you don't know how the malpractice works, I have a patient, I'm suing the doctor. Now, I'm in great ball game because I just saw you are interrogatory. Your interrogatory states that you have a million dollar, $3 million coverage insurance policy. So I can stand to make up to a million dollars. So I'm going to start negotiating with the other party and that's between those two. I want 50, I take 150, no I take 75, you go back and forth, back and forth. I will give you a case I worked on now. I sued Cigna. Cigna owned the surgery center 1.7 million dollars, filed the law suit in 2011, had to go to mandatory arbitration. Cigna, four lawyers, sitting there. They owe us the money. They just didn't want to pay. They kept saying that we didn't bill on time etc, etc. It was all BS. Judge came in and judge says, let's go, let's settle this today. We got six hours. I want 1.7. Do you know what Aetna came in at? Anybody want to take a guess what they stood at, what number? They owe 1.7 for seven years. What do you think they offer? 50,000. 50,000 and the judge is looking at me like what do you think? What do you mean what do I think? I'm not going to do this. Well, you know, you got to do this, why don't you come back at 1.2. 500,000, she cut off right off the bet. Got down to 900,000, got down to 700,000 and I said and this is a true story, people know this, at 700,000, I already gave away a million dollars.

    So I said you know what your honor, I'm not going through arbitration, let's go to trial. You know how much a trial is going to cost 150,000? I said it's not the money, it's the principle. She slammed her hands on the desk and said you think there is principles in this courthouse, you're mistaken, my son. Lesson to learn. Yeah, we settled for 325,000, otherwise it was the trial. What are you going to do? Again, when lawyers get involved, the ball game changes, keep that in mind for the rest of your lives. So again, we talked about the restricted covenant, legalities, two-year two-miles top, if you're going to sign any contract. Nonsolicitation clauses. All your contracts will say that you can't approach to help or approach the patients for two years because those patients belong to the practice and if you solicit them, the doctor has a right to sue and guess what everybody does it. Nobody sues, it's just the way it goes. It's current practice. They have the clause under that you can't go after them but very few people do that. Last but not least as we finish up here, how are we doing on time? Okay, good. Again, what it's all commonsense. Unrestricted license, DA number privileges at hospital or surgery center and right to participate in healthcare plans. Any question? I think academic, we're not going to talk about today. Things that you could negotiate how much the doctor will promote you, that's a new thing now with the social media. The contracts some are written that the doctors that the associate is responsible for all social media. You want the practice to be responsible for social media to promote you, the new associates joining the practice, that's jointed the group etc, etc. That's a biggie. Termination with or without cause. You always want a contract. So if you're going to get terminated, you need a cause. With the cause, different ball game. Without cause, termination means, I walk in, I don't like the way you're dressed today, I want you to leave.

    There is nothing you can do about that because that's a clause for termination without cause and with cause. You want a with cause clause in your contract, so there is a reason. You got a felony, you lost your medical license. Well, there is good reason that I can't keep you anymore. These are the things you have to remember. Second thing is if you do get terminated, if you do leave, all your monies have to come to you. Contract I just read a couple of weeks ago that upon termination, all monies that come in the first 30 days will be given to the associate. Any monies that come in 31 days or later belong to the practice. Who gets paid in 30 days? Okay. No body. It takes four to six weeks on the minimum, correct? So that was a heck of a clause they try to sneak in and we had to fight to get it out. Again, things to watch out for associate. If you're an associate, you're going to a partnership or a group, if they are dragging the feet giving you financial information. I put this on here, I don't know if I get in trouble nowadays, if the spouse is involved in the management. This is just life. I don't care if it's he or she. Spouse involved in the management. It's the whole different ball game and if you had that situation, it's not a good one. Again, when you're there after a while, you have to be comfortable. You can't go to work as an associate with the stomachache because you feel the pressure. You're not producing enough your productivity is the way what you think it should be, then that's not the practice for you. You have to want to get up and go to work because when you get up and go to work, it's not a job, it's something you like to do. You're physician, that's the idea here. Final comments, contracts should be specific. Again, never ever be afraid to walk away from any contract. If it's not fair, don't get pressured into it and don't give your contract to your attorney till you reviewed it yourself and you circled the clause as you're not sure of what they mean and then you get clarification from attorney and you decide if you wanted it in there. You're going to hear I can't live with this. This is what your attorney would say, I can't live with this. Well, good, maybe you can't, but I can, depending on what the clause says.


    And then it goes back and forth between the attorneys and next thing you know you have a $2000 legal bill. And again yes, use a lawyer who specializes not in contract law but specifically healthcare contract law. They have to know what's going on. Same thing for your accountant. An accountant that's involved in healthcare who knows what it means when you're writing off a big percentage of the BlueCross bills, if you're writing off a big percentage, the accountant will understand that. So you're not paying a phantom income. You're not paying money that you will never receive. So it's very important. Any questions? Yes please. Honestly, it's not even a center, a surgical suite. A surgical suite. CRNAs will come in, [inaudible] [0:32:48] you call them up, will come in with the power equipment, whatever you need. You don't have to put it upfront and you do it. Then when the proposal starts coming out, you're going to have to fill out the proposal for bundle payment and .I already told guys this, you are going to do the bunion in the office. You're going to do the shrink dinky lipoplasty, not going to be paid for down the future. That's a vendor push. In economics, that's called the vendor push. The vendors are giving lectures all over place lipoplasty, lipoplasty, gets $41,000. If the surgery center hospital under contract for 4000 per case on a flat rate, are they going to allow you to do that? You want to do that in your office. Patient satisfaction is going to go from 20% to 40% of reimbursement. So Medicare by law is out of committee, they can send you a letter saying how do you feel. You okay? You had a procedure done. Still hurt but we can't pay you doctor. We can't pay you. We're on all-come base now. These are the things you have to watch out for. So to setup, usually the fault question is, can I do an office based surgical suite? Is it legal? Yes. Okay. Plastic surgeons have been doing it for years. Dentists have been doing surgery for how many years. An impacted wisdom tooth has a higher mortality rate than you do in a couple of hammertoes in your office. So you got all that reality set in where is medicine going from economics standpoint and adjust to it. Don't fight it, adjust to it. And you will see more and more doctors, orthopods look it, doing scopes in their office now because they are ready for bundle payments. They will pay them 11,500 to do the ankle scope in their office. So understand you have training but then you have to apply that training where it will benefit not only you but also benefit the patient. No other question. Thank you very much.


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