By John Carruthers, assistant editor, October 01, 2013
The process of moving a practice, whether it’s down the road or to a different time zone, brings with it opportunities and challenges which can run down even the most enthusiastic practice owner. By planning well in advance, gleaning the lessons of colleagues’ experiences, and resolving to make oneself adaptable, practitioners can greatly ease one of the more intimidating events of one’s medical career.
The 'lightning bolt’ moment
For every dermatologist who moves their practice, there’s an identifiable moment where the “should I?” of moving becomes “how do I?” according to dermatologist Neal Bhatia, MD, who in 2010 left his Milwaukee practice for private practice in California and a position as interim program director of the division of dermatology at Harbor UCLA Medical Center.
“For me, there were a number of personal factors that went into the move, as well as the fact that a group of physicians I was affiliated with was sold to a hospital system, which can be a disaster for a dermatologist,” he said. “Between that and wanting to move closer to family, I made the decision fairly quickly. The minute you make that decision, it’s important to start making preparations. In my case, it was six months in advance.”
Other physicians are driven to relocate because of expiring contracts or leases, or economic conditions that make staying in place untenable. Fort Smith, Ark., dermatologist Sandy Johnson, MD, found that her office was becoming too small for the growing practice.
“Before our move, we were renting, and we had the ability to purchase and grow,” Dr. Johnson said. “Our first plan was to purchase the clinic that we had been renting, but it turned out not to be a viable option. So that original plan was replaced by almost three years of looking for land, drawing up and modifying plans, and then carrying out the 12-month construction process.”
Managing the logistics
As a physician with responsibilities to one’s patients, the moving process can be somewhat complicated. For Washington, D.C., dermatologist Andrew Lazar, MD, who has moved from practicing in Illinois to California to his new D.C. home since 2010, the very first step each time was a call to set in motion the process of becoming licensed in the new state. [pagebreak]
“The moment you know where you’re going, you need to start the process as soon as you can, because it takes a long time to get a license,” Dr. Lazar said. “The sooner you get things started, the sooner you can be working. No matter what, get that process started as soon as you make a commitment as to where you’re going to go.”
To ease the process, Dr. Lazar recommends employing a service that will handle the paperwork and red tape of licensure. The cost involved, he said, is offset by the lack of bureaucratic headaches.
“There are a number of organizations that will actually do the busywork for you. They charge you about $600 per license to do the work. It’s not a small amount, but at the same time, I’m not calling the registrar of the medical school to make sure a form was sent or calling the head of residency to make sure it’s sent on the right stationery,” Dr. Lazar said. “During the last move, I was told by the person who is working on my applications that one of these licensing agencies has requested copies of where I trained and did my residency four different times. It was sent four times through the service, but they didn’t have a record of receiving it. It was worthwhile for me not to have to deal with that.”
In addition, Dr. Bhatia recommends that young physicians in residency look ahead to future licensing situations, obtaining licenses for their states of training and home states, in addition to where they plan to practice initially.
“The best advice that I can give anyone in residency is to get the license of the two states that you think you may move to in your lifetime,” Dr. Bhatia said. “Even if you don’t keep them up, you can re-enroll when you move there because you already have your foot in the door. I was able to get set up in California much more quickly this way because I’d applied for a license there during residency.”
After licensure is dealt with, there remains the issue of malpractice tail insurance. Typically, insurers will offer either a one-time payment option or a slightly more expensive multi-year pay period. Academic institutions, Dr. Lazar said, will sometimes cover the insurance themselves, depending on the length of one’s employment. Large groups, he said, can also be persuaded to cover the payment as part of their expenses. [pagebreak]
“Doctors never think about the fact that you can negotiate give and take between a group or institution. There’s a lot of give and take depending on the size of the organization you’re dealing with,” Dr. Lazar said. “Most of us aren’t used to that. We don’t think about the business aspects of it, and it’s important to realize it.”
Enrolled Medicare providers must also report changes in address to their contractor to ensure the least possible disruption in payment. While earlier is better, according to Dr. Lazar, under the law, one must report the move within 90 days. Whether a doctor is moving or becoming a Medicare provider for the first time, he or she should visit www.cms.gov/MedicareProviderSupEnroll to learn about the requirements and/or update his or her entry in Medicare’s Provider Enrollment, Chain and Ownership System (PECOS).
If one is splitting a dermatology practice from a group, Dr. Bhatia said, it’s important to address the accounts receivable situation as quickly as possible. The nature of the split, he said, often dictates the financial arrangement.
“Some groups will offer you either sustained payoffs over time or you can take an immediate lesser buyout, as you would from the lottery, rather than the long-term payout of what is truly owed you,” Dr. Bhatia said. “If it’s an amicable split, a lot of people will take the longer payout. If not, most people will take the immediate buyout. There’s an upside and a downside to both, depending on your situation.”
Getting the word out and starting anew
The process of informing and transitioning patients, Dr. Bhatia said, is a multi-step one. Once he had informed his affiliated physician group (90 days before he intended to move), Dr. Bhatia began to plan for his patients’ futures, taking on fewer and fewer new patients and beginning to send follow-up cases to colleagues in the area. [pagebreak]
“As 90 days turns into 60 days, you’re starting to make patients aware that you’re going to be gone or that you’re going to be seeing them for the last time, which can be very sentimental,” he said. “From there, you’re also making sure that those patients with melanoma or high-risk therapies are getting their future care addressed sooner rather than later. You don’t want them falling through the cracks.”
Depending on the state that one is leaving, there are a number of varying responsibilities upon the physician to ensure they have done their best to notify patients.
“When I was in Illinois, I talked to the state medical society and found out what the legal obligations were to close your practice. There, you had to post a notice in the newspaper a certain amount of time in advance,” Dr. Lazar said. “In dermatology, you don’t have many true emergencies. In the case that you do, whoever took over the practice or who you referred the patient to would get the phone call.”
Some physicians make efforts to notify each patient individually, but according to Dr. Lazar, doing so can incur substantial cost.
“In dermatology you might have 40,000 active charts in your practice. To try to contact all of those people is an exceptionally difficult and exceptionally expensive process. It’s going to cost you about a dollar per contact.”
Instead, Dr. Lazar posted the legal notice in the paper, then made arrangements with the physicians taking over his two practices to take over the phone numbers of the practice and notify each patient as they called. The charts remained where they were, he said, which greatly improved the continuity of care. [pagebreak]
Even for cross-town moves, Dr. Johnson said, a select number of patients may miss all the signs and notifications.
“We’ve been in our new location for two-and-a-half years. When we moved, we took out ads in the paper, bought a billboard near the old location for a few months, mailed notices, and sent out messages with our automated messaging machine,” she said. “We still have patients going to the old location. It’s important to promote the move not only months ahead, but for some time afterward.”
In addition to patients, Dr. Johnson said, insurers may require more than one notification, or at least a follow-up to make sure that the payment transfer proceeds smoothly. More than one payer, she said, had trouble with the change of address that resulted in a two-month delay in payment.
Contract language may prevent some physicians from informing the patients about anything but the fact that they’re moving. Birmingham, Ala., dermatologist Elizabeth Martin, MD, negotiated with the clinic system she was leaving — for a location literally across the street — on the method she would use to notify patients of her move. Eventually, she sent each patient a postcard with a map of the new location in relation to the old one.
“While they weren’t too happy about me leaving, it was a fairly amicable breakup,” Dr. Martin said. “We agreed mutually upon the wording on the card.”
Some physicians have an even more difficult time. In a recent Leadership Institute session she was leading at the Summer Academy Meeting in New York, Dr. Martin answered an attendee’s inquiries about notifying patients of his impending move under the strictest of contractual tethers. The dermatologist, she said, was allowed to tell patients he was moving, but nothing more than that. [pagebreak]
“That’s a difficult situation for a dermatologist, not being allowed to contact any patients,” Dr. Martin said. “We got a discussion going, and the general recommendations were to make sure his information was up to date and easy to find via Google, and tell patients that they could search for him after the move.”
Even if one leaves the practice in another dermatologist’s hands, Dr. Bhatia said, it’s typically good business to make oneself available for the new practice owner and patients for a short period of time following the move.
“You want to maintain as much good faith as you can so that you can leave on a positive note,” he said. “Ultimately, you want to leave a good legacy.”
Leave a note
The list of parties that must be notified of a practice move, even a short move, is quite substantial. Before the boxes are on their way to the new office, be sure to tell:
- Referral colleagues
- Contractors and vendors (janitorial, biohazard pickup, information technology)
- Medicare and other insurers
- State medical board
- Medical associations, including the AAD
- The U.S. Postal Service
Getting up to date
Moving your practice? Update your information with the Academy at www.aad.org/Account/Profile, or through the Member Resource Center at (866) 503-7546.