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Inspired by numerous medical integration consultants and coaching organizations, chiropractors have increasingly pursued the integration of medical services into their practices over the past few years. Driven by the dual goals of providing comprehensive healthcare solutions and tapping into the broader healthcare spending of their patients, chiropractors are wise to approach this integration cautiously. Too often, chiropractors, excited and perhaps pressured at integration seminars, sign agreements only to later regret it due to several issues: (1) their lawyers disapprove of the advice they received, (2) they underestimated the complexities and risks involved in expanding their practice, (3) they think integration lone will fix fundamental business issues in their practice (e.g., lack of effective marketing and sales), and (4) the integration ultimately fails due to business needs of their practice that are actually intensified by adding the “weight” of an additional service line. What are some of the most significant areas of disappointment for those whose integrations did not go smoothly?

Addressing Underlying Business Problems

Using integration to solve an existing business problem can be problematic. For instance, if you’re pursuing medical integration because your chiropractic patient volume has decreased, you should first understand why your core business is suffering. Evaluate your marketing efforts – are they effective? Do you have a dedicated sales team comfortable discussing your services and fees with potential clients? Since medical integration patients typically come from your core chiropractic business, a decline in chiropractic patients will undermine the success of any new medical services you offer.  Fewer chiropractic patients will likely mean fewer integration patients.  

Navigating Legal Complexities

Many chiropractors are drawn to the promise of medical integration but often overlook the legal intricacies involved. Are you aware of the self-referral issues related to creating a second Tax Identification Number (TIN) for the medical entity? Do you understand the state and federal requirements for physician supervision? It is illegal for a newly formed entity to refer patients to itself for certain specific services. Chiropractors often find themselves following a “one-size-fits-all” model touted as standard practice with consultants and “their lawyers” who just flow the deal instead of making sure their clients understand the laws, risks and options.  It’s common for practitioners to reconsider medical integration when informed about state and federal self-referral restrictions.  Additionally, not all states require a complex “management model”; some, like Florida and approximately 12 other states, permit simpler direct services models.  Chiropractic leaders must do two important things here:  (1) accept that one size fits none, and (2) measure twice; cut once!

Clients who work with the Florida Healthcare Law Firm benefit from deep industry (both business and legal!) experience and dedicated legal support. Our team doesn’t merely dabble in healthcare law; we specialize in comprehensive representation of healthcare providers and almost every type of healthcare business. Whether you’re a new physician starting a practice or a chiropractor looking to integrate your practice, our attorneys are aligned with your success and committed to navigating the complexities of healthcare regulations to protect your interests.

By: Jeff Cohen

Founder, Florida Healthcare Law Firm

Private equity is once again showing a strong interest in acquiring medical practices and healthcare businesses. This wave of acquisitions differs significantly from the activity seen in the 1990s, where public companies focused on aggregating gross income to boost stock prices. Today, private equity investors aim to maximize profitability by achieving efficiencies, consolidating large groups for leverage, and developing new income streams. While stock options, warrants, or shares may be part of the deal, many transactions are all-cash, often based on earnings. To secure the full price, sellers typically must remain involved in the business to maintain or even increase revenues.  

Physicians, in particular, need to understand the nature of these deals and the factors that influence them. “Private equity” refers to private investors, usually a group pooling their capital, who purchase a portion or all of a company. These investments are notably larger than those from venture capital firms and do not involve publicly traded entities. The goal of private equity is to invest in mature businesses, enhance their profitability, and eventually sell their ownership stake to another buyer within three to five years. In contrast, venture capital firms often invest in start-ups, acquire complete ownership, and seek control over the company.

Key Issues for Sellers:

1. Buyer Experience: Sellers should evaluate the buyer’s experience in their specific industry. Since buyers promise to grow the seller’s profitability, it’s crucial to confirm that they have a successful track record in similar businesses. Sellers should also seek detailed plans on how the buyer intends to achieve growth.
2. Impact on the Seller: It’s important for sellers to understand how the acquisition will affect their income, their operations and their business operations.  Will there be significant cultural changes? Will there be major shifts at the executive level? What kind of control will the buyer exert? What effective voice will the seller have in the issues that direct impact them?  Speaking with other businesses that have been acquired by the same buyer can offer valuable insights into what to expect post-acquisition.  If the past is any predictor of the future, the happiest sellers in these transaction are the ones who have an eye on retirement within he next 3-5 years.  
3. Buyer Plans: The timing of additional investment rounds is critical, especially if the transaction involves stock options or warrants. If the buyer is in the early stages of their investment cycle, it could take several years before any stock has real value, as the initial phase often involves significant debt accrual.  And that says nothing at all about dilution or the subordinated nature of the interest.  Unless the sellers pick the right buyer, the sellers with stock or warrants will likely just paper a bedroom closet with them!

Understanding these factors can help physicians and other healthcare business owners navigate the complexities of selling to private equity and ensure they make informed decisions that align with their goals. 

By: Jeff Cohen

Founder, Florida Healthcare Law Firm

IV hydration therapy providers are increasingly expanding their menu of services to include aesthetic services such as Botox, injectables and other aesthetic and/or dermatologic skincare services. The growing trend of embracing aesthetic treatments not only enhances the comprehensive care offerings available under one roof but is also useful in attracting a broader clientele and unlocking new revenue streams for an IV hydration therapy business. Today’s wellness landscape is more competitive than ever and staying ahead means differentiating through not only customer service, clinical quality but also with in-demand service offerings. Adding aesthetics can keep a practice competitive and attracts new patients who seek convenience and comprehensive care.

First Five Steps:

1. Ensuring that a practice has appropriately licensed and trained Clinicians who are allowed via their scope to perform the aesthetic services it plans to offer is key. Though regulations vary from state to state it is typically a licensed APRN or PA;
2. Structuring the appropriate supervisory relationship ensures that each APRN/PA is appropriately supervised by a licensed and qualified physician, and that the supervisory relationship is properly documented in accordance with the state’s laws and regulations – which most typically consists of offsite supervision with a written agreement and protocols between them;
3. Applying for a Health Care Clinic Establishment Permit (HCCE) permit (not to be confused with a health care clinic license from AHCA) enables a provider to order aesthetic treatment supplies from vendors; The purpose of the HCCE permit is to allow the business to purchase prescription drugs in the name of the business for use by the practitioners of the business instead of having each practitioner within the business purchase the prescription drugs under his/her individual license for use on his/her individual patients.
4. Patient Intake Documents – It’s crucial you incorporate service specific informed consents covering each aesthetic service you will offer; Each informed consent should disclose detailed information regarding the healthcare treatment or procedure, including its potential risks and benefits and alternative treatment options. These documents should be written in clear, understandable language that the patient can comprehend, should be signed voluntarily by the patient and should be documented into each patient’s medical record prior to treatment.
5. Checking with your insurance carrier prior to offering an enhanced line of services will not only ensure your insurance coverage is up to date, but also that it covers the scope of the aesthetic services you will offer, whether as an “endorsement” or “rider”. An endorsement is a modification or addition to an existing insurance policy that changes the terms or scope of coverage, for example to include additional procedures, specialties, or types of claims that are not typically covered under the base policy. Similarly, a rider is a provision added to an insurance policy to provide additional coverage for specific risks or situations. In the context of medical malpractice insurance, a rider might be used to extend coverage for certain procedures, locations, or activities that are not covered by the standard policy. Both endorsements and riders allow policyholders to customize their insurance coverage to better suit their needs and mitigate risks specific to their practice or circumstances.

Please contact us at Florida Healthcare Law Firm to discuss in more detail the growth of your IV hydration business today and how your business can stay ahead of the curve and address each of these compliance measures proactively. 

In today’s competitive healthcare landscape, staying ahead by expanding to include wellness and elective offerings is growing increasingly popular.  Adding aesthetics to a medical practice platform keeps the practice relevant to patients, and competitive in the marketplace and may even attract new patients who seek convenience and comprehensive care.

Five Key Concepts to Consider:

1. Scope of Practice. Owners will want to ensure that the medical practice has the appropriately licensed and trained Clinicians to perform the aesthetic services the practice will offer. In Florida, this consists of ensuring that each midlevel provider (APRN, PA) has a supervising physician and that the documentation in place between each of those clinicians adequately complies with Florida’s scope of practice requirements as indicated by the various professional boards;
2. Physician Collaboration. Each Clinician must be appropriately supervised by a licensed and qualified physician, and the supervisory relationship must be properly documented in accordance with Florida’s laws and regulations. Depending upon the nature of the practice, and the comprehensive menu of services being offered, there might be additional qualifications of the collaborating physician, such as requisite board certification(s);
3. Biomedical Waste Program. Medical practices need to be appropriately registered as a Biomedical Waste Provider with the Florida Department of Health. This entails submitting an application to the state, and scheduling an inspection where the state will ensure you have contracted with one of its approved biomedical waste transporter servicers, and that you have development a completed operating plan;
4. Patient Intake Documents. Service specific informed consents covering each aesthetic service offering must be incorporated before any patient is ever touched. Each informed consent should disclose detailed information regarding the healthcare treatment or procedure, including its potential risks and benefits and alternative treatment options. These documents should be written in clear, understandable language that the patient can comprehend, should be signed voluntarily by the patient and should be documented into each patient’s medical record prior to treatment; and
5. Insurance. Check in on the medical malpractice insurance coverage to ensure it is up to date, and that it covers the scope of the aesthetic services aesthetic services you will offer, whether as an “endorsement” or “rider”. An endorsement is a modification or addition to an existing insurance policy that changes the terms or scope of coverage, for example to include additional procedures, specialties, or types of claims that are not typically covered under the base policy. Similarly, a rider is a provision added to an insurance policy to provide additional coverage for specific risks or situations. In the context of medical malpractice insurance, a rider might be used to extend coverage for certain procedures, locations, or activities that are not covered by the standard policy. Both endorsements and riders allow policyholders to customize their insurance coverage to better suit their needs and mitigate risks specific to their practice or circumstances.

Embracing aesthetic treatments can not only enhance a medical practice by incorporating medical and aesthetic treatments under one roof, but it can also attract a broader clientele and open new revenue streams for the business. It may be time to embrace change!

In Florida, when a practitioner provides specialty health care services, such as dermatologic or aesthetic and cosmetic skin services, that practitioner must be supervised by, or collaborate with a Florida licensed physician who is board certified in either dermatology or plastic surgery. Furthermore, that practitioner’s supervising physician may only one office, in addition to the physicians primary practice location and the office in which the physician supervises must be within 25 miles of the physician’s primary place of practice or in a county that is contiguous to the county of the physician’s primary place of practice. However, the distance between any of the offices may not exceed 75 miles. The office being supervised must also A physician who supervises an office in addition to the physician’s primary practice location must conspicuously post in each of the physician’s offices a current schedule of the regular hours when the physician is present in that office and the hours when the office is open while the physician is not present. Whether you are a supervising physician or are a midlevel provider who collaborates with a physician to operate your medspa, it’s important to ensure that this relationship is compliant to avoid any unwanted regulatory scrutiny. 

Let’s dive into why Direct Primary Care (DPC) models are an absolute game-changer for those in the healthcare field, regardless of whether you are a physician provider (MD or DO), or midlevel provider (APRN or PA). If you’re tired of battling with insurance companies, offering services under a DPC model might just be the solution you’ve been searching for. So, what’s the deal with DPC from a provider’s perspective? Instead of being bogged down by insurance bureaucracy and constant paperwork, you can focus on what you do best: caring for your patients. But it’s not just about the increased quality of patient care —you also can’t ignore the financial benefits of direct primary care. By cutting out the third-party middleman insurers, you can offer your services at a fraction of the cost of traditional practices, and get paid more, faster. This not only makes healthcare more accessible to your patients but also allows you to focus on what matters most: improving health outcomes and operating a successful business that thrives based upon a combination of these concepts. So, if you’re ready to take your practice to the next level and revolutionize the way healthcare is delivered, DPC might just be the answer. 

In a momentous move, the Federal Trade Commission (FTC) has enacted a nationwide prohibition on non-compete agreements, signaling a profound change in labor policy within the United States. This unprecedented decision carries extensive implications for both employers and employees within the healthcare sector, necessitating crucial reconsiderations given a fresh regulatory framework that oversees the non-compete limitations generally present in employment relationships.