a sonographer's guide to entrepreneurship

Talking tech

Episode 22: Top 3 Questions of the Week

Each week I chat with techs across the country that have questions about starting or operating their ultrasound businesses. In this episode, I’m answering the top three questions for the week: how do I make sure to provide a turnkey service? Who pays for the radiologist or cardiologist’s interpretation? What are the differences in working with physician practices versus working with Nursing Home Facilities? Let’s dive in!



Grab a seat and a cup of coffee because you just enrolled in Ultrasound Business School. We are obsessed with all things ultrasound and are here to take you on a journey through the messy and the magical side of business ownership. Think marketing, contracts, vendors, admin, growth mindset, and that’s just the tip of the iceberg. This is the Talking Tech Podcast, a sonographer’s guide to entrepreneurship. Here’s your host, Jennifer Lindsey.

Jen (00:33):

Hey, hey! Excited to do another top three questions of the week. I have gathered these not only from questions that I’ve gotten in DM’s and things like that but also from our clients as well. So as they’re kind of moving through and having different ideas of types of services they’re providing, I get questions all the time from them. And so, I thought I would do another top three questions of the week podcast episode. And so today, we are talking about how to provide the best turnkey services for your physician clients. We’re going to talk about who pays for the interpreting physician. I get this question all the time from people who are considering starting their own business and trying to figure out what costs are going to be associated, you know, on a regular basis for their business expenses. And so I wanted to cover that a little bit more deeply today.

And then we’re also going to talk about physician’s offices versus nursing home services because this is one that I get quite often from clients of ours who are looking at their market to see which types of groups are going to be the best fit for them to add in some additional types of services. And so, I wanted to go over those three today and get some real specifics out to you as it pertains to these three questions. So let’s start with how I provide the best turnkey service for my physician clients. It is so important when we go in; we want these contracts for the long term. And so being able to provide something that, when you go into these offices, you are really just an extension of them. There’s not a whole lot of extra stuff they have to do.

It’s not stressful; it’s easy; it’s seamless. They don’t have to go find a bunch of extra vendors because you’re coming in. You want to provide all that stuff to them in kind of a one-stop shop turnkey service. So some of the things get out your notebook; let’s make some notes on here. Some of the best ways to provide that great turnkey service for the practice so that you can continue to keep those practices on your roster for the long term. It is much easier and less expensive to keep happy clients than to keep adding in more clients because you’re not doing the best job keeping the ones you’ve got. And so bringing in obviously the equipment and the technologist is going to be super easy. They don’t have to; some of the benefits here because they don’t have to go buy equipment, they don’t have to buy anything on that side, they don’t have to have a capital expense.

When you bring in the equipment and the tech, you know, providing those services in the office is much less stressful for them because there’s no capital expense. And so, if you remember, we’re bringing this service to that niche market where we’ve got physicians who are ordering ultrasounds, but they’re not ordering enough. Like for example, OB/GYN, physicians, or cardiologists. Most of those types of doctors have their equipment because they order so many that it makes sense for them to hire a tech, buy a machine and have that machine running five days a week. That makes sense for an internal medicine doctor, a neurologist, for example, a family practice physician, a really small cardiology office, one in a smaller town, or a small OB/GYN office. We’ve had those clients before.

For our own business here, there’s some of the types of clients that we provide services to. It makes the most sense for those types of practices that don’t have enough ultrasounds for them to make a capital expense and then have that equipment just sitting there most of the time and try to find a tech that’s either PRN or part-time and have that person be available when they need them. This is an amazing option for physicians to have basically an ultrasound department in their practice without having to do all that extra stuff. So when we’re bringing in the equipment and the tech, providing those services on a scheduled basis on their patient load makes so much sense for those types of physicians. You also want to make sure that you’re bringing in all of the supplies as well.

Now for our mobile business, what we have opted to do, and I know most of our clients have opted to do this as well, we don’t do any laundry service. So if we’re doing echos, if we’re doing OB/GYN services where we need the covers and those types of things, or for echos where we need a patient gown. Any of those types of things we do buy disposable gowns, those types of things. So it depends on the practice, but we don’t do any laundry. So if they want to have you use, you know, their gowns, those types of things, it would just go in with their laundry with all the other stuff that they’re doing, the procedures that they’re doing in their office. So bringing in the supplies so they don’t have to buy anything extra is important.

We don’t want them buying gel for us; we don’t want them buying gloves for us—those types of things you want to have. And what is a great option for that is to put it in one of those little milk crate carts that have a handle and wheels. You can get them at really any; you can probably get them on Amazon at this point. I used to always buy them at like Office Depot. The last couple, I think, I’ve gotten on Amazon. But it makes it so much easier because you can put each of those in every single office that you’re going to and just have them put them in a storage closet out of their way when you’re not there. That way, you’re not carting around a ton of supplies. Plus, each office usually needs something a little bit different.

If one office is doing OB/GYN studies, you’ll want to make sure you have probe covers and those types of things for that. If another office is doing echos, you want to make sure you’ve got all the leads and all of those things in that particular supply little package there at that particular office. And so it just keeps you as the tech from having to take, you know, your computer, your system supplies, your com, you know, all the different things that you’re providing, that you’re bringing in the office. That’s such a nice option just to have one of those little carts, those roller carts at each physician’s practice stocked full of the things you’ll need while you’re there. The other thing that’ll be great to have and provide as that turnkey service is providing a PACS and a scheduling system.  As a caveat and a side note, this works great for physicians who can read their own studies but don’t want to spend a ton of money on their PACS.

We had a cardiology client who has since moved out of state, so we no longer service his office. However, when we were working with him, he was a smaller cardiologist, and he had many patients in his practice that needed an ultrasound. Still, he was just sending them all to the hospital, where he had privileges. And so for us to be able to come in and provide those services there, he loved that because we could also supply the PACS for him, so he didn’t have to go out and get PACS. We went there a couple of days a week and provided him with services in his office. And then we were also able to do some of his vascular stuff that he couldn’t read, and we sent those out to, you know, our radiology vendor. And so it was nice to be able to have that.

He loved having that in his practice, and I think it’s great for some of those practices that could read their own studies but didn’t want to invest in a big PACS system. We have a neurology client that we do that as well. They’ve got five different locations here in Indiana, and we provide services there to them. And then it’s all from each of the locations housed on our PACS. They’ve got two neurologists that read their carotid studies on our PACS. It’s all right there and just easy for them to pull down. The cool thing about the PACS system that we use and that our clients have access to on our vendor list is that it also has a scheduling system, which is nice because this way, they can literally just put their patients on our scheduler. They don’t have to call and tell us what time to be there.

It auto-populates the time it takes us to do each exam. So if we say, okay, we want our echos to be 45 minutes and our carotids to be 30 minutes. They don’t have to call or look at a sheet to figure out how long they should be booking these patients. It just auto-populates into our system. It’s all web-based, HIPAA compliant, but web-based so that we just look and see; okay, what time are we starting tomorrow? Awesome. We’ll be there. We know exactly what’s on the schedule, making everything so much easier to have everything in one system. Years ago, before we started using this, we had literally like three or four logins for our clients because we needed to have a scheduler, we needed to have PACS, we needed to have multiple different ways for them to get us information and to have all of that housed in one system has just been so nice for us.

It’s become a hub. Everything’s there. The office has access to it. So they’ve got two tabs, they’ve got a scheduler, and then they’ve got the PACS where they can go in. If the physician wants to look at the images, maybe they’re not reading their own studies but still know what they’re looking at and want to go in there and look. They can view all those studies as soon as the report has been completed. And then it houses all of the reports there as well for the required archival, year time. I think it’s seven years now or eight years. So it houses everything there for them. And what I love about it, too, is we all know physicians still love to use fax machines. I still can’t figure that out. It’s 2020 at this point. I thought fax would be gone by now, but we all know physicians love their fax machines, so this system will email or fax a report directly to their office once it’s been completed.

And that’s all just something we do as a quick setup when we add on a new client. And that is, as I mentioned, something that our coaching clients also use for all of their physician clients. And so it makes it nice to have that pushed out immediately to them. But we all know how it works. It’ll say on your end that the fax has been sent; it will say it was successful, but they can’t find it, and the patient’s there, and they need it so that the doctor can go over the report with them. So what I love about the PACS is that they have immediate access to it. So instead of having to call us frantically to try to find the report like they usually would to a referral destination, right? They can just log on, go to the patient and print off the fax directly from the system.

It’s just right on there as a PDF inside the patient’s account on the PACS system. And so it’s made it so nice for them, really easy. They can also save down CDs if they want to; let’s say the patient has an issue they’re sending them out to a surgeon, and they can actually save all the images down on a CD directly from the PACS as well. It’s a pretty user-friendly and robust system that we utilize. And that’s something that’s important when you are looking at providing that really good turnkey service to your physicians. Okay, so another thing that is so important when you are providing that service in the office is to have an understanding of the basic billing procedures to be able to assist with questions. Your doctors, likely because you are now providing services in their office, have probably never billed ultrasound before.

And so they are going to have some questions. They are going to want to at least have some general idea of how they need to bill it, what types of diagnosis codes they can utilize, and those types of things. And so having that basic understanding is important. It’s something that we go through with our clients for our Ultrasound Business Academy, and we do that because we think it’s such an important basis of knowledge to have when you’re providing those services in the office. The other thing that’s really important to provide is referrals for interpreting doctors for those who can’t read their own studies. So when you’re going into a family practice, group, or an internal medicine group, they usually send out all their ultrasounds, not reading anything outside their wheelhouse or area of expertise.

To provide a referral for interpreting doctors is going to be really important. And that’s something else we have in our vendor list because it’s so important to be able to provide those services as a referral. Another thing that’s really important that I want to make sure you guys know, too, is having some details provided to them in paperwork form. In the beginning, and I know I’ve chatted about this too on some of the trainings that I’ve done, but an implementation meeting in the very beginning when you’re starting a new account is absolutely crucial. And most of the things we coach on, if you guys have been following me for a while, you know we’ve had our own mobile ultrasound business here in Indiana for almost 17 years, and everything we coach is things we learned the hard way.

We didn’t have a coach on mobile ultrasound when we first started. It’s why we created our coaching division because we made so many mistakes, and you learn from experience. However, those learning-from-experience moments take a lot of time and cost you a lot of money. And so we know from experience that having an implementation meeting in the beginning, is so important because if they, even though the service is a turnkey service in general if they, don’t know specifically beforehand everything that you need, the first few days that you go in, there are going to be very hectic. And you don’t want them thinking, oh my gosh, why did we sign on for this? This is stressful. My staff’s stressed out. Nobody knows what’s going on. There’s only a little that they need to do for you. But if you don’t set expectations in the beginning and talk with the people that are going to have their hands in this service, because if you think about it when you go through the sales process and finalize the contract, you did that with the doctor.

But all the doctors really doing now at this point, once you implement and have the service in the office, is writing the order; he is relying then on his staff to schedule the ultrasounds to make sure the reports came back, to make sure he gets the reports and reviews them. You know, all those backend things that the doctor’s going to have nothing to do with. You need to make sure that you are talking with those people, the schedulers, the billers, the office manager. It’s great to have that implementation meeting in the beginning just to set expectations and be able to answer any questions beforehand. And I promise you doing that will make those first few initial times in their office much more seamless and less hectic for everyone. So we do a protocol binder that we have for them so that all the paperwork in one place, they can pull it down if they have a question, it’s got our contact info in there.

We have multiple pages of paperwork that explain exactly how the service works. Step-by-step instructions for how to get on the PACS, how to get on the scheduler, how to put patients in there, and login information so that they have all of that right there at their fingertips. Especially if you know someone’s out sick that usually does the scheduling. We want them to be able to, you know, whoever’s filling in for them for that day, I want them to be able to pull that protocol binder and be able to take a look and say, oh, okay, here’s exactly how I do this or here’s their contact information. Because I’m not usually the one who calls Advanced Imaging when I have a question, so they have our contact information right there. You know, when if there’s someone new, someone needs to get ahold of us, all of that’s just right there in a protocol binder specific for them.

Those key points are things that are so important, and over the years, we have really tried to make our service and then explain to our clients how to make their services in their physician offices as turnkey as possible. So that’s just easy. There’s only a little extra work for the office, and it’s a seamless way to really provide an amazing service so that you’re keeping these contracts for the long term. So I mentioned one of the things that is really important to be able to provide as a turnkey service. Kind of one of those points is an interpreting physician referral for those doctors that aren’t reading their own studies. So if we’re moving on to question number two that, I get a ton is: who pays for the interpreting physician? So let’s move on to that. There are two major ways you can be set up to provide these services.

So you can either be set up to provide services on a contract basis where you are doing a fee-for-service model, the physician’s office’s billing insurance directly, or they’re getting paid directly for the procedures you are providing in the office. Then they are paying you a service fee rate for coming in and providing those ultrasounds in the office, or you can do the billing. You are then set up as a mobile IDTF, you’re billing, you’re getting paid from insurance directly, and the scenarios are a little bit different based on how you are set up. Now I have a lot of recommendations for that. So, people, I’m going to do just a quick side note on this. We have many people who really want to be able to be in on the billing side of things, which is great.

However, you have to understand, and I know I’ve mentioned this before, that when you are set up as a mobile IDTF, you have to have all of those things in place before you can even start billing insurance. So you have to buy your equipment because the serial number for that equipment has to be on your Medicare paperwork, but you can’t actually bill any patients until the insurance companies credential you. So you’ll have a system sitting at your house doing nothing, making no money while you’re making payments on that, waiting for all the paperwork to be completed. So for our clients, just as a side note for everyone thinking about starting their own business and doing it where you are the one billing, our suggestion always is to be doing all of that. But in the meantime also have some clients where you’re providing a fee-based service so that you’re actually making money while you’re waiting on the credentialing paperwork to be finalized.

Because if you have to buy your machine anyway, you might as well be making some money on it instead of having it just sit around collecting dust while you’re waiting months and months for the insurance companies to decide that they want to finalize your paperwork. So that’s just a side note from me for some kind of business advice on that end. But it is set up a little bit differently based on how you’re; you are completing your business. So if you are looking at providing things on a service basis where that doctor’s office you are providing the services in is the one billing insurance, they are the ones who are paying the cardiologist or radiologist for the interpretation. So if you’re going in, you’re providing the services, the doctor’s office is billing insurance, they are going to be billing insurance directly for the ultrasound service itself and the interpretation.

And then they are going to be obviously the radiologist or cardiologist in this scenario is the one actually reading. So they purchase the interpretation from the interpreting physician. So it’s actually coming out of the physician’s revenue, not yours. So that’s important to note when you are looking at, you know, your budget and all of those things, this is not something that comes out of your pocket. Now I have to say here there is a caveat to that, and we go in very, very deeply with this, with our clients and our Ultrasound Business Academy, because there are specific rules for Medicare patients that your physician needs to ensure compliance with its anti-markup ruling. There are certain ways that they have to bill the interpretation portion for Medicare. So don’t just go out and tell your doctors they can bill globally for everybody and pay the interpreting doctor because that’s not how it works for Medicare patients.

But in general, they are getting paid for both. They are buying the interpretation from the interpreting doctor for everyone but Medicare. Now if you are the IDTF, if you’re the one billing and you’re getting paid for both the ultrasound and the interpretation, so in that scenario, you are the one then who would pay the radiologist or cardiologist, but you’re getting money for that already. So you’re paying them out of your gross revenue. You already got paid from insurance for the interpretation, and you are buying that then from the radiologist or cardiologist. Usually, industry averages, just to give you guys an idea, are about $25 for the interpretation for general and vascular. They’re usually a little higher for OB because that carries so much more liability insurance. And so doctors usually charge a little bit higher because their insurance for those types of exams are higher.

And then for echo interpretation, usually anywhere between $45 and $50. But those are a higher reimbursed procedure. And so, you’ll see that that falls in line if you start looking at what the actual Medicare allowables are for those different types of ultrasounds. You’ll see that that’s usually less than the actual Medicare payment, which is where that anti-markup rule comes in. Hopefully, I’m not confusing you guys with that. Medicare patients are done a little bit differently to comply with certain rules when the doctor is not reading their own study. So who pays for the interpreting physician? If you are providing the service on a service fee basis where the doctor is billing, the doctor pays for it. If you are an IDTF and you are the one billing and getting money from insurance, you are billing for the ultrasound and the interpretation. Then you’re buying the interpretation from the radiologist or cardiologist.

All right, and then another question, let’s move on to number three that I get a lot is physician offices versus providing services to nursing homes like skilled nursing facility groups. The cool part about this is that the rules and regulations for physician offices in nursing homes are different because they’re two different types of entities, and so they have two different types of rules and regulations. If you have been hanging out with me for a while, you know, I discuss this really often that once you at going into a physician practice, once you bring in the tech and the equipment, you cannot charge by the patient any longer if you’re just providing staffing. So you’re going into an office where the doctor already has his own equipment, they’re at the office, you can charge by the patient as the tech just providing staffing. But once you bring in the equipment and yourself as the tech, you can’t do that any longer.

There are rules with pay-per-click arrangements, which is not a legal way to set things up. However, you do then charge by the hour in this scenario. So we always suggest our clients set half-day or full-day blocks in the office based on their patient load. So let’s say you have a smaller practice, and you’ve determined their patient load would be sufficient to come in a half day a week. So let’s say you set every Tuesday from 8 to 12; it’s easy. They’re not calling you trying; hey, I’ve got patients can we schedule a time for you to come in? If they already know and you’ve already determined that is the best timeframe to be able to provide the services to all the patients that they usually have on a regular basis, then they already know what day you come in.

They just pop patients on the schedule. It’s super easy. There’s a lot less back and forth. So that’s always something we suggest. And then for bigger patients, like I was mentioning, you know, we had that cardiologist that we worked with for quite some time before he moved out of state, and he had enough patients where we were going a couple of days a week, full days because he had, you know. Obviously, he is a cardiologist; he had a ton of echos he was doing, he was also doing quite a bit of vascular studies, as well. And so we really teach our clients specifically high enough how to figure all that out logistics-wise so that you’re making sure you’re covering enough time to be able to provide services to all the patients that they have but also scheduling in a logistical manner where it makes sense.

So the best way there is to do that, as I mentioned, is billing by the hours, the way to do it legally, and then setting things up in half-day or full-day sessions as often as you need to fulfill their patient load. Now for skilled nursing facilities, it’s important to understand your market leverage here, okay? Nursing facilities usually get a set amount for each patient that they have for Medicare. So unlike a physician’s office, where they’re billing insurance outright for each procedure, a skilled nursing facility will get a lump sum of money, and then all of the procedures that they provide for that patient comes out of the sum they’ve received. So if we look at the fact that a patient who needs an ultrasound usually needs to get transported by ambulance to the hospital, right? They get their ultrasound done there, we know, you know, it can be $1000 to $1500 a lot of times for ultrasounds at a hospital.

They also get then a separate bill for hundreds of dollars for the interpretation from the radiologist or cardiologist. And so altogether, for them sending out a patient to get an ultrasound, it can be a couple thousand dollars for them. So if you have groups in your area that don’t have access to onsite ultrasound, this could be a huge win-win situation for the nursing facilities because you can charge by the patient in this scenario. It’s a different contract setup for these facilities, but you could provide the services, you know, let’s say between $200 and $300 for an ultrasound, including the interpretation in there. And so you have kind of a one-stop shop for them where they’re used to spending a couple thousand dollars, and now they can have someone come right into the office, their patient doesn’t have to get transported, which we all know is a huge deal for patients.

They don’t have to get transported; they can stay in the nursing facility, and you can charge a couple hundred dollars instead of a couple thousand dollars, especially because, like I said, they’re getting that lump sum. So they want to get amazing procedures completed for their patients, with wonderful service and all of that naturally, but they’re going to want to do it at the best rate possible because it’s coming out of a lump sum for them. And so I always tell people, if that’s something you’re considering, it is an amazing win-win situation for everybody involved because it’s such a huge cost saver for the skilled nursing facility. It’s such a big deal for the patient not to have to get transported. Especially, you know, at those nursing facilities, those patients, they want to stay in the place where they feel comfortable transporting them around is kind of asking for trouble a lot of times, right?

Because of the state that they’re in. And so being able to have that done right in the facility is going to be so wonderful. And so if you’ve got nursing facilities local to you that don’t have access to that, that’s definitely something I suggest looking into as an option for them. Because it’s such a win-win situation, kind of all the way around. And because you can charge by the patient in that scenario. And so what I suggest is having, again, like a lump sum that you charge, let’s say it’s $300 just as an example, you include the interpretation with that. So in this sense, you would be paying the radiologist or the cardiologist directly, but you’ll be getting that money obviously from the nursing facility. So let’s say you charge $300 for an echo to come out to do that, and the echo read is $50, you’re charging $300, you’re paying $50 to the cardiologist, and you’re making a $250 profit on that.

Now out of that, of course, comes your business expenses and those types of things, but to be able to have that as an option and just really make it a turnkey service where they’re not getting billed by the ambulance service and the hospital for the ultrasound and the interpreting doctor for the interpretation is just such a great way to be able to provide those services right there in the nursing facility, group, you know, place. And so I think that’s something that is really important to look at if you’ve got those in your area that don’t have access to onsite ultrasound. All right, guys, those are my top three questions for the week. How do we provide a turnkey service? Who pays for the interpreting physician, and then what’s the difference, and how are they setting up a physician’s office versus a nursing home facility? As always, I love being able to provide these podcasts on a regular basis so that you guys can really delve into the specific areas of ultrasound and be able to kind of feel more confident as you’re running your business or as you’re considering starting your business. And so until next time you know it, I’ll be over here cheering you on.


Ready to see what it takes to start your own mobile ultrasound business? Grab our completely free startup guide and learn how you can make a thousand dollars a day with your own business. Head to our website, www.aic-ultrasound.com, to check it out.

your strategy-obsessed ultrasound business coach.

I'm Jennifer -

Welcome to the Talking Tech podcast, where we answer your questions about legal, marketing, admin, sales, and so much more. After nearly 20 years in the industry running our own mobile ultrasound business and helping techs across the country do the same, I'm so excited to bring you industry insight, mindset, productivity, business tips, and inspiration to help you design the business of your dreams.

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