First 5 Years of Practice: Pearls and Pitfalls

By Michael G. Haas, MD (bio)

The last several years of your life have been dedicated to learning about medicine and ophthalmology in general, even more extensively if you have pursued and finished a fellowship. That knowledge will certainly be the foundation for beginning your career, but you are now starting all over, again. In today’s economic climate especially, you now have to pay attention to both the medical aspect of practicing ophthalmology as well as the business aspect. Ignoring the business aspect will be career suicide.

When interviewing and evaluating your potential new practice, listen and watch for any red flags. Your gut instinct is often right. This is not to say that most practices will not have something that is a red flag, but heed your instincts. Any red flags should be thoroughly discussed with your partner if you are in a relationship, or an attorney. Spousal unhappiness due to job location or inability to further his or her career will often be the reason a job may not work out. Make sure this is a family decision.

Before you begin, you will need several months to complete all of the necessary paperwork. First up is your medical license. Everything hinges on your new unrestricted license. After that you need to apply for and receive a Medicare number. You will need both of these prior to any application to the literally hundreds of different potential insurance panels. Your current employer has probably already done the initial contractual rates (another headache), but you should have the same or a very similar rate as your new business. Hopefully somebody in the office will be able to assist you with this. Plan for credentialing to take a minimum of six months.

I would highly recommend having an attorney review any new contract offer you receive from a practice. Nearly half of ophthalmologists will leave their first job for one reason or another within 3-5 years. Items such as non-compete agreements, buy-ins and buy-outs, what happens in case of termination (who provides the “tail” malpractice coverage) are all issues that have the potential to be financially devastating depending on how your contract is written. The money you spend on an attorney will be well worth it.

You will likely be getting your first “real” paycheck as well. The temptation to go on a spending spree may be great, but don’t forget to start saving (if you have not already) for your retirement. The surest way to a difficult retirement is to neglect saving. Start right now, even if it is small. If your employer offers a 401(k) match you need to max this out. It is free money for you. I would also recommend maxing out your 401(k) entirely at the $15,500 yearly amount.

Additionally, it is time to think of life insurance and disability if you have not done so already. You need to secure the long-term future of your family. Accidents can and do happen and you need to assure that you are either practicing or that your family is protected in the event you are no longer able to perform your duties as an ophthalmologist. If you do buy disability insurance, pay for it with after-tax dollars (not pre-tax dollars from the business). If you buy with after tax dollars, the benefit money will not be taxed upon collection. If you paid with pre-tax dollars then expect upwards of a 30-40% reduction in payout dollars due to taxes. And now it is time to learn more about the business.

For those that enter into a large group practice, the business side may be fairly easy. Some offices have administrators as well as full time coders and billing office staff. Even in these practices, proper coding and billing is ultimately the responsibility of the physician. With dwindling reimbursements, improper coding can cause the loss of substantial income over time. You need to know which services you can bill for using the proper ICD-9 (soon to be ICD-10) codes. For example, a patient coming in with flashes and floaters may get an extended retinal exam with scleral depression. For a PVD code, you cannot bill for extended ophthalmoscopy. However, for a diagnosis of PDR or ARMD you can bill for extended ophthalmoscopy, provided there is an adequate drawing of adequate size in the chart note. Pay attention to all the details!

For those entering into a smaller practice, you very well may not have anyone looking over your shoulder when it comes to billing. The AAO offers CME modules on coding which can be a good start to understanding the documentation required for various types of billing. Not to mention it is a great way to earn CME credit. Modifiers are important as well. Some diagnostics are unilateral while some are bilateral. You will quickly need to learn the difference, or risk collections being held up or even denied.

Whether you’re in a large or small practice, marketing will be critical to your future success. If you are a retina doctor then you will still need referrals from comprehensive ophthalmologists and possibly even optometrists. It is important to hit the pavement and introduce yourself to your local referring base. If you are a comprehensive ophthalmologist (or any other sub-specialist) you also need to hit the pavement. Your referring base will largely consist of optometrists and family or internal medicine physicians. You need to think about what your stance is on co-management of cataract surgeries (many optometrists will not refer to you if you do not co-manage), and you want the primary providers to understand they will receive a timely consultation note for the patients they refer. Part of pay-for-performance for primary providers will be to have an ophthalmologic exam on every diabetic patient within the past year. Let them know you can help them with this. Overall, networking with the local providers (whether they are MD’s, DO’s, OD’s, NP’s or PA’s) will be critical to your long-term success.

Be very friendly with your staff. They can help make your life a lot easier. Make it a point to become very familiar with the surgical centers and staff as well. Ultimately you will need to learn about human resources, and the hiring and firing of employees. In the first two years this will not be much of an issue for you, unless you have just started a new practice. You will eventually have to balance being friendly with being a leader. You need to set the expectations for your office staff, and you also need to invest time and energy into training them. Good employees want to learn and if you can offer nuggets of wisdom in the practice of ophthalmology then everyone benefits. Expectations will never be met if you are not a good leader. Show up on time, or better yet before that. You will always be busy. If you are not seeing a patient then catch up on journal reading, or track patient flow and find ways to make it more efficient. Staff need a good leader to be effective and this cannot be stressed enough. Your practice will be what you make it, so prepare to work for everything. If you’ve never heard of John Pinto, now is the time to buy and read a copy of John Pinto’s Little Green Book of Ophthalmology.

As a young surgeon, it is very important that you gain experience both through the volume of surgeries you perform and by continuing your education. Typically an ophthalmologist is required to have a minimum of 25-30 hours per year of CME. It is very important to attend an annual Ophthalmology meeting at least once per year. Stay current. You will additionally be able to network with other young surgeons and other ophthalmologic providers, while learning about the cutting-edge advances in ophthalmology. You never know when these connections can help you down the road, whether it is with a specific patient problem or even potentially a new position if your current job does not work out.

Take advantage of the new Ophthalmology O.N.E. network. You can stay current with the different journals, find highlighted or outstanding recommendations, or even pick up some CME. There are also great videos that can help your own surgical abilities.

Networking and marketing goes beyond just the local providers. To help expose you to the community and also to help your mental sanity, consider joining a local community service organization. Consider joining your local Rotary, Kiwanis or Lions Clubs. Networking with others in the community can go a long way to establishing your reputation as a quality provider in your area. Ultimately, the word of mouth referrals from people that know you and/or have been seen by you will go the furthest. Treat every patient as a family member and you will quickly build a loyal patient base.