Hello, down here, welcome to Podiatry Practice Mastery, where
we're helping you take your practice to the $1,000,000 mark
and beyond in your own personal production.
So I, I wanted to start today with a couple of questions.
I got as I've been talking about urgent cares, there was a doctor
that reached out to me and said, hey doc, how about insurance
coverage for your urgent care? How is that?
How is that working? And I said let me check because
I don't know, I just see patients.
And so I asked my one of my office managers here and they
said for the most part, when patients make an appointment
online, there is a kind of a scrubbing field, meaning it says
we do not take this and this and this insurance, You know, just
want you to know that if you want an appointment, there is a
cash pay amount. But otherwise, you know, pretty
much don't make the appointment. That's how it is online.
If they do it on the phone, same thing.
We tell them the insurances we take and we don't take and then
they can choose to see us if they're in a hurry.
Sometimes they do see us and we have a reasonable cash pay
amount. It's usually the amount that
insurance would pay us. I think for probably a new
patient, it might be 150, depending on level Level 3,
maybe level 4 is 200. And then X-rays might be, I
don't know, 50 bucks or something like that.
And then any other things that we do would just be kind of a la
carte for those patients. So I'm, I'm having patients that
come in and pay. We've had a few patients that
make the appointment and they don't know that we don't take
their insurance because for example, there's something here
called Tufts Direct. So we take Tufts, but Tufts
Direct is a, a Medicaid or mass health product and we don't take
that. So they'll come in.
There's a little bit of confusion there.
So it's not perfect in terms of checking insurance.
So this is something that we're learning as we're doing it, but
I still think filling up the schedule is worth it with this
urgent care model right now. Another question that someone
asked me is they said, I want to start using a virtual scribe
like you do. What is really necessary for a
virtual scribe? So I've, I've talked extensively
about Murali. He is my third virtual scribe.
I, we chose virtual versus in person just because our, our
office, our, our rooms are small and we didn't, frankly, I didn't
want someone's in my space all the time when I'm there.
And So what I need for a virtual scribe is a cell phone.
So I have a second Samsung cell phone and we have basically I do
a phone call via Microsoft Teams.
So Microsoft Teams, the same number, like I don't know if
you've noticed this, but with Zoom or Teams, you can connect
via a link or there's a phone call number that you can do.
And so this is the same phone call that I make every single
day and it connects me to India where Murali is now Murali was
ascribed. So all I really need to do my to
do it would be a teams account, which my my scribing company
does the and the one I use currently is IKS that they
changed companies recently. It's called IKS and they they
have ACA teams repeating event on my calendar.
I click that event actually now it's just this auto save on my
on the phone. I do it and I don't use that
phone for anything else. I just basically I recharge it
every night. I put it in my backpack and I
that's all I need to, I need a phone and I need a Teams account
that they give me. That's really it.
And then when I'm training him, I use the team's video or the,
you know, the actual video to share my screen.
So I have in my office, I use daily, I use 7 computers, so six
treatment rooms and then one in my office.
And usually the one in my office is my base where I will come
back. And when I was training Raleigh,
I was sharing my screen, showing him how to do the notes,
checking my notes with him. He could see me as I'm going
through the notes. So in the beginning it takes a
little bit, especially since we just switched medical records,
but that is all you need. Now someone asked about do I do
like a written consent saying that they're there?
No, but I introduce morale to everyone.
I don't do a written consent. I just say hey, there is someone
on this device and I point the phone in my pocket and he is
going to be taking notes for me. There are a couple of other
methods that use video and you would put an iPad, a small
little mini iPad and they can see things.
The one that I use doesn't use visual.
I, I think it takes a little bit more bandwidth to be on a video
call and I try to verbalize what I'm doing with the, with the
patients like, and he, he gets used to it.
You know, he knows, I talk about, you know, thickened
toenails and he, he learns now what I'm doing and everyone, all
the patients always ask me, is he AI?
And I always say he's like five times a day.
Murali is not AI. And for anyone that is Indian,
his real name is Murli. But it took me about six months
to learn how to pronounce Murli. And so I just call him Murali
because I've been doing that for for so long.
And one day I actually tried to change and called him the right
thing. And he said, why are you calling
me my real name? I said, because I finally
learned how to pronounce it. But he is he's my age.
He is worried about his job because all of his colleagues
there are, are losing their jobs because of AI.
Now, I don't think AI can do what Murali can do.
I, I do not think right now it can he, like I, I've, I've
talked about this before, but like, for example, today I'm,
I'm, I'm, I'm going to record my, my day of a Thursday, but
this is a Friday and we're going to probably see 45 patients.
He's going to do all the notes. He's going to remind me, he's
going to send prescriptions, he's going to order PT, he's
going to review MRI's. He's going to, he just, he gets
bogged behind and he just kind of like catches up with me.
So it's, it's, he's busy just doing notes and I just sign off
on them. So it makes it a lot easier for
me. And I'm just at this point, I
don't think AI is there. It might be there in the future.
I think if you're doing AI for like an HPI review of systems
discussion, I think things like that are OK, but currently it's
not quite there and it is worth the investment.
So the investment for me anyways, about thirty $35,000 a
year and I think it's well spent and I and I pay it, it kind of
goes through the office meaning so then it actually comes
directly out of my salary, not even out of operating expenses
because I'm the only one that uses him.
So it comes directly out of my salary.
So it's it's worth it in my opinion for how much benefit I
get from it. OK, let's go into the day.
First patient was swift #3 on the right foot, a 61 year old
man. I usually do 4 Swifts.
So he's going to schedule one more in a month and then I do a
three month break. I am seeing improvement with the
Swift. Next was a 33 year old man with
right plantar fasciitis #3 out of 6 for Shockwave.
Next was a 56 year old female. She had right Achilles
insertional tendonitis. She got the Pelto special night
splint foam rolling morning stretch.
The dynamic demonstration with I do a orbival and then I
prescribed her meloxicam. I'm going to see her back in
three weeks for possible ultrasound and shockwave.
So she is aware of that. And next patient was a 40 year
old female. She had a care reflex done on
the right toenail and she also had a wart.
So we did lesion destruction on that wart.
She didn't want canthroidin because it made her blister too
much. That's why she didn't want
canthroidin. So I just did salicylic acid.
Next patient was a 68 year old female with left heel pain and
she also had some midfoot pain. Last visit I gave her two
injections into the midfoot with cortisone and she is totally
better so I'm not going to see her back unless that midfoot
pain comes back. She already has orthotics.
Next was a 70 year old female #3 out of 6 for bilateral plantar
fasciitis. She is going to start feeling
better. I tell patients usually at the
5th visit. Next patient was 61 year old
female for Q 10's and #1 and we did that.
I finally figured out the correct template and I recently
did on our on my YouTube page. I'm starting a mod Med kind of
video series. The same thing I used to do with
Athena kind of sharing how to do different types of templates
that are kind of challenging and different types of tips.
So if you have any cool mod Med tips tell me or or any questions
I'll try to figure them out because it was kind of a
struggle. So I'm trying to make some
resources on the on the Podiatry practice mastery YouTube page.
Next was a 44 year old male. He was here for only a nail
evaluation. I've really never had this
before. He had some like longitudinal
lines in his nails and he was concerned and so his nails look
fine. But I really talked to him.
He had some hallux limitis. So I talked to him about
functional hallux limitis, gave him some information and said
that could just be hitting the top of the shoes.
And I talked to him about the shoe liner test to make sure
that they were big enough. He was actually pleased with the
the consult. I thought it was kind of a
weird, weird one. Next was a 50 year old female
for right plantar fasciitis. She did number six out of six
Shockwave. She is already feeling better.
I'm going to see her back in six weeks and I did an office visit.
So always the last shockwave I have.
I haven't talked about this for a while.
So I have a last shockwave handout.
So I give them that. It kind of prepares them for
what's next. And so since I'm discussing
about that, I think that that is appropriate for an office visit.
So once again, these are all within my treatment sheets that
I that I use and I print out for patients.
Next Whiskey tenza #4. So this gentleman I made a
little video on 75 year old man has neuropathy pain.
Q tenza #4 So the first three, first two he didn't feel
anything. Third one, he's like, wow, all
of a sudden my feet don't hurt. So if you're new to Q Tenza or
considering doing it, and this is what the reps say, it usually
takes about 3 applications before they notice some
improvement. And now he's like, wow, I can
like my feet feel good, I can sleep, I can everything else is
fine. And he was like, how long is
this going to last? And I said, I don't know,
probably 3 months. That's why you do it every three
months. So he is feeling better most of
our Qutenza. So kind of a snafu about
Qutenza. There are two ways you can do
it. One is called buy and bill.
That means we buy it for like an absurd amount of money.
I think it's like $4000. And then we bill the insurance
that $4000 and you make a little bit maybe like 10%.
The other option is you go through a specialty pharmacy and
then they pay for it and then you just do the application fee.
I prefer doing the application fee because you make, I don't
know, maybe $400.00. I think it is 4 or 500 for the
application. Real easy thing to do the buy
and bill. The problem is it messes up our
billing. That really messes it up.
But like it's one of those things, just like when I used to
do like Dermagraft it, it's a, it's a high capital expense and
you have to cut that out of your production.
So we did a six month review for the doctors and I had like, I
don't know, however much money I had produced, maybe, I don't
know, 5 or $600,000. And so I had to take out like 50
of that or 40 of that because it was the buy in bill for the Q
10s. Just like we don't really cut
out other stuff from the doctors.
But like these things that it's not really just a cost like you,
you, you buy it for 4000, you earn 4000.
It's not you don't, you know, we just cut those things out.
We don't do it for AF OS and everything else.
We just do it basically for these high ticket items.
So it kind of inflated my my monthly number.
So like when you see the numbers, I try to get 80 a
month, 80,000 a month, I'll get to the $1,000,000 for some
months it's 90 some it's 100. And so some of that that shows
it might be falsely inflated. Next patient was he had a 78
year old man with a left 5th digit corn.
Basically just had a hammer toe. I've really, I just talked to
these ones about shoes, anatomic shoes and I trimmed his little
corn for him. Next was a little 2 year old boy
that kind of jumped off something and his feet hurt for
a couple of days. They were concerned about a
first metatarsal fracture, got X-rays.
You know at a 2 year old you can't really see much in the
X-rays, but we got the X-rays. He went to the urgent care and
they were still concerned so they came and saw us.
Everything looked fine. Next was a 72 year old man with
a left 5th MPJ pain and I did an ultrasound.
I saw some a fusion around the joint.
I did a cortisone injection and I recommended him to have more
of a an anatomic shoe. I think it happened with his
golf shoes that were a little too narrow or some other type of
shoe that didn't have any give on the side.
So I did X-ray, ultrasound and then the cortisone He talked to
me about there is a golf shoe if you if you need an anatomic golf
shoe to recommend, I think it's called squares squares shoe and
I and I don't it's kind of a weird spelling with AZ, but if
you need a one to recommend, I have a shoe buying guy.
That's how I tend to do it for my patients.
Next was a 79 year old female. My buddy, he had to go do a Liz
Frank repair during lunch and so I had to take over one of his.
His routine morning is Thursdays.
And so I did one of his nail care patients for him.
Next was a 69 year old female that I did a a biopsy.
She came in for like a skin lesion on the dorsal lateral
foot. I did a two 2mm punch biopsies
and since I have to do a lecture on biopsies or dermatology here
at a local conference I took little pictures to show how easy
it is. Basically it should take like
one minute and if it takes longer let me know I'll try to
help you out. Next was a 43 year old female
that had wart with a kanthordan and and she is this she's a
runner. She's back to running because
she had a tib Ant insertional issue going on and she is
getting better with shockwave. Shockwave #5 out of 6 basically
no pain. I'm going to do one more and
then she should be fine. Next was a 56 year old man new
patient got a diabetic foot exam.
He had a wart in the right heel as well.
I did canthered in on that and he had a one thickened nail so I
did nail debridement and actually a nail sample for him.
Next was a 68 year old female for left anterior ankle.
Kind of a neuritis. She had a anterior ankle.
She had like a ganglion I think that popped and kind of adhered
some of the tissues down there with kind of a nerve impingement
kind of pain. And I'm doing shockwave.
She's on number session #2 out of four.
She's not really seeing much improvement yet, but we're we're
doing that. Next was a 71 year old man.
He's post MRI. I was concerned for him.
I did 2 injections to the first MPJ.
He did not get better on the MRI.
We got an MRI because it wasn't getting better.
And it was actually one of these or I don't know how you guys do
it there, but it was like an orange, an orange alert, meaning
they sent me like a text message, e-mail, all from the
MRI place. And it was because he had a
stress fracture in the first metatarsal neck.
And I'm not sure exactly sure what happened for that, but it's
been painful for a while for him.
So what we ended up doing is shockwave #1 out of four,
focused only or non radial only. This was the soft wave that we
had in this office and I, so I build the fracture code.
I gave him a dispensed him a Cam boot.
Actually he had his own Cam boot and then I did number one out of
four. He's going to set those up.
And usually for I'm offering patients now, just so you know,
with Shockwave, I'm saying, hey, most patients do it once a week.
That's fine. If you want to kind of get the
get them done faster, you can do them every 72 hours.
So I do offer doing it twice a week for some patients.
They just want to get it done faster versus like spreading it
out. Next was a 78 year old man after
PT he had some balance issues and he he's going to be getting
orthotics. He, he forgot to pay for them or
we forgot to ask him for money so didn't get his orthotics.
He's going to be getting them. Next was a 44 year old female
left second toe cyst. This was kind of interesting.
She had a cyst in the proximal phalanx, probably like a maybe
like an echondroma. So I recommended that she get an
MRI and then we'll see you kind of like offloading in a surgical
shoe or a boot or something like that.
Next was a left hallux 70 year old female that had a WAVY left
hallux that was kind of lytic and thickened.
I took a nail sample for her. I don't think it's a fungus.
I think it's an onycolytic nail that's kind of WAVY because it's
detached and so I'm not going to see her back.
I am going to call her with the results in.
The last patient of the day was a 49 year old female with left
fourth met base fracture. This is the she's #3 out of four
for non radial only that for that fracture and we're going to
get one and the next one in the fourth visit, we're going to get
an X-ray and then I usually do a six week follow up.
So she is doing well. So that was the day.
Once again, I'm putting together a challenge.
If you want to challenge yourself to get to the
$1,000,000 mark, I'd love to do it with a, with a few people.
I've had some people that are interested in the, in the emails
that are coming out. You should see them.
If you don't get the e-mail, shoot me one Don at Podiatry
practice mastery.com looking for a few practices that want to
kind of if you're struggling, I don't like it's hard to
implement. That's the thing I find like I,
I talk about these ideas here, you might like them, but
actually making change when you're in a busy practice is
hard to do. That's why I put together this,
this six month challenge, basically this we can all
challenge. Yeah, I can be challenged, you
can be challenged and we're going to put together like it's
a mastermind. So we're going to be a group of
docs working together. So that's what I'm working on.
If you're interested, let me know and we'll talk to you more
tomorrow.