What can I do if I want to do House Calls (and get paid) but also accept Medicare?

Yesterday I spoke to a podiatrist who is currently starting a house calls practice. He is trying to maintain a more conventional practice to keep a steady income while he builds his house call based practice. He had a couple of great questions:

Keep in mind that I am not a healthcare attorney and I'm not actually a business advisor. I am just a podiatrist who started doing house calls and makes a great living doing so. But here is my understanding of the rules after having discussed these exact questions with my own healthcare attorney years ago.

1. Can I accept Medicare and bill Medicare for the patients I see in the nursing home, and then when a patient with Medicare has emergency and needs to have an ingrown toenail removed at home can I see them and have the patient pay me cash for the house call?

No. Either you accept Medicare and you are a Medicare provider, or not. If you want to opt out of Medicare you have to follow a specific formal process to get out of the Medicare system. I used a healthcare attorney to help facilitate that process. I now send a renewal to Medicare in order to confirm that I continue to be "opted-out" every two years. 

Any services provided to a Medicare patient by a Medicare provider must be billed directly to Medicare....never, ever to the patient. 

However, if you "opt-out" of Medicare you're no longer a Medicare provider. You are then free to charge patients directly. This is what I do. I charge whatever fee I want. Currently $300 for a new patient evaluation.  The patient pays the fee to me, right then. My service is completely unrelated to Medicare at that point...because I am no longer a Medicare provider. But be to be clear, I have had the patient sign a Medicare Opt-Out Agreement so that I have a record that they understand I am no longer a Medicare provider. This also is a requirement of Medicare.

There are huge fines and penalties for doctors who bill Medicare patients directly (if they are are still in the system as a Medicare Provider). My solution, as you might have guessed, is to opt out and refuse to participate in the Medicare system.

2. Can I have a patient sign a form understanding and acknowledging that they know I'm not going to bill Medicare...and that we both agree that they're going to pay me in cash? Is this legal?

No. As mentioned above is illegal to bill a patient for services that you provide if you are still in the Medicare system as a Medicare Provider. You must opt out and stop becoming a Medicare Provider if you're going to bill patients directly. The Opt-Out Agreement is only a specie form (signed by you and the patient) to inform patients that you used to be a Medicare Provider, but that you are no longer a Medicare Provider...basically that you quit working with Medicare. The patient then understands that you are not going to bill Medicare, they cannot bill Medicare, and none of your services are ever going to be reimbursable by Medicare. 

3. Can I opt out of Medicare and then also work under another doctor's Medicare number to see patients in the nursing home?

No. But I have heard from lots of doctors that they do it anyway. It is a very common arrangement where a new physician out of school will see patients working with another physician. Many doctors believe that this is a gray area. The doctor without a Medicare number treats a patient. The doctor with the Medicare number cosigns the note and bills Medicare. It seems like this is reasonable and should be legal.

I did discuss this with a healthcare attorney. I paid thousands of dollars for their team to research this and determine whether or not it was reasonable. In the end they said that it was more than a "gray area" in fact it would likely be ruled is downright illegal if ever tested in court. If you were to do this you could wind up paying large fines to Medicare.

To me, this just seems far too risky given the small amount of money that you can actually make the Medicare patients under another doctors Medicare number. This certainly exceeds my personal tolerance for risk.

4. Can't I just get a separate office address and separate business license so that one is a Medicare location and one isn't?

This also seems like it should be completely reasonable. However, as explained above, it is the doctor that is the Medicare provider not the office location. This question actually came from an anesthesiologist when I was in the operating room recently. She was asking me whether or not she could start up a concierge-type chronic pain practice on the side to make some extras cash.

Because she is an anesthesiologist and has to see patients in the hospital, a large portion of her patients are Medicare patients. Her anesthesia group of course bills Medicare. That being the case, she has to accept Medicare and bill Medicare for those patients.

Her thought was that she would set up a separate business that was different than her anesthesia practice which would only focus on chronic pain medicine, and where she would bill patients directly for services provided at home. Again, this seems like it would be totally reasonable however appears to be illegal.

With Medicare, it's really very simple...either you're in or you're out.

Dr. Christopher Segler is a successful podiatrist who only does house calls. He practices in the San Francisco Bay area. He has recently written a book teaching other doctors how to set up housecalls-based practice that is more profitable and avoids all the administrative hassles associated with insurance companies and Medicare.

Order your copy of the House Calls Startup Manual: How to Run a Low-overhead, High-profit Practice and Get Your Life Back 

House Calls StatUp Manual

How to Run a Low-overhead, High-profit Practice and Get Your Life Back

The latest version of the book that will get you started to a successful house calls practice is here, and as of today it is ranked as the #1 New Release in Physician & Patient Home Care on Amazon!

House calls may be the oldest form of health care delivery, but they are making a comeback. Why? Because it may be the simplest, fastest way to a highly profitable practice and great lifestyle. This book is the definitive step-by-step how-to manual for any doctor, physician or podiatrist who wants to shift from a standard-office based practice to a more profitable house calls based practice.

Here is the story about the book and how the author thrives in this medical practice model:

After completing comprehensive foot and ankle surgery residency training and winning multiple awards from the American College of Foot & Ankle Surgeons and the American Podiatric Medical Association, Dr. Christopher Segler opened a standard office-based podiatry practice immediately out of residency. Through hard work and creative marketing efforts, his practice grew rapidly, and he soon had a full schedule—too full, in fact. He found himself leaving for the hospital in the dark, sitting in the office charting on the weekends, and wishing he had more time to actually talk to patients.

Searching his soul and trying to determine what he wanted to do with the next phase of his career and his life, he made a list with two columns: "Everything I love about the practice of medicine" and "Everything I hate about the practice of medicine." After completing the list, he realized that a standard office-based practice had too many related items in the hate column and too few in the love column.

He then set about creating a practice that would include only items from the Everything I love column, and vowed never again to do anything from the Everything I hate column. The result was a simple fee-for-service, cash-based practice, free from insurance hassles. He opted out of Medicare, stopped accepting insurance, and jettisoned his office and all associated overhead.

The result of that bold move, was a period of fear followed by experimentation that eventually yielded a high-profit, low-stress practice. He now walks his son to school, travels extensively, and earns more money than he did from his previous standard practice, while working a fraction of the hours he used to put in.

This book shows exactly how he built his practice—and how you can, too. The reasoning behind opting-out of Medicare is explained. He outlines the methods he uses to attract patients who are willing and eager to pay on the spot for home-based care. He tells you best practices he learned through trial and error while he built his new model: what works and what doesn’t. If want to get your life back with a high profit, low stress practice, this book will save years of fear, help you skip the experimentation phase, and ensure that you land high on the learning curve so you can start earning a real living and live a great life, right now.

Order your copy of the Kindle version NOW!

Dr. Christopher Segler
Doc On The Run

If I Opt Out of Medicare Can I Still See Medicare Patients for Podiatry House Calls?

Yes! In fact far more profitably.

You can (and likely will) see Medicare patients if you opt out of Medicare. However you will not be restricted to charging Medicare allowable rates. You can charge whatever is appropriate for your time. You can charge a house call fee sufficient to provide caring, non-–rushed care for your elderly patients. And you will not have to wait for Medicare to pay you.


If you have previously accepted Medicare and then opted out of Medicare (after you realized that it was very difficult to offer high-quality caring interactions at low Medicare reimbursement rates), you must notify every medicare-eligible patient that you have Opted Out of Medicare. When you see a Medicare patient after you have opted out of Medicare you are entering into a private contract. The following are conditions and requirements of a private contract between the physician (you) and the Medicare “beneficiary” (the patient).

REQUIREMENTS OF A PRIVATE CONTRACT BETWEEN THE PHYSICIAN/PRACTITIONER AND BENEFICIARY:

• Be in writing in print sufficiently large to ensure that the beneficiary is able to read the contract
• Clearly state whether the physician or practitioner is excluded from Medicare.
• State that the beneficiary or his or her legal representative accepts full responsibility for payment for the physician’s or practitioner’s charge for all services furnished by the physician or practitioner.
• State that the beneficiary or his or her legal representative understands that Medicare limits do not apply to what the physician or practitioner may charge for items or services furnished by the physician or practitioner.
• State that the beneficiary or his or her legal representative agrees not to submit a claim to Medicare or to ask the physician or practitioner to submit a claim to Medicare.
• State that the beneficiary or his or her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician or practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
• State that the beneficiary or his or her legal representative enters into the contract with the knowledge that he or she has the right to obtain Medicare-covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare- covered services furnished by other physicians or practitioners who have not opted out.
• State the expected or known effective date and expected or known expiration date of the opt-out period.
• State that the beneficiary or his or her legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• Be signed by the beneficiary or his or her legal representative and by the physician or practitioner.

Here is a copy of the exact form I use to notify patients I have opted out of Medicare:

Medicare Opt-Out Agreement form

Please note: You are required to have your patients sign a new contract every two years.  I simply have every Medicare patient sign a copy every year whenever I see them.

Check with your Health Care Attorney to make sure you are in complete compliance.

KEEP ORIGINAL COPIES of forms!  Retained original signatures of both parties are required by the physician for the duration of the opt out period (as in forever). These must be made available to CMS upon request. Place a copy in the patients new patient folder at their initial visit before items or services are furnished to the beneficiary under the terms of the contract.

Dr. Christopher Segler is not a health-care attorney and is not offering legal advice.  However he is a successful Concierge Care House Call Podiatrist who figured out how to help patients by offering cash-based services free of insurance-related hassles under a simple house call practice model.  If you have a question about how to start a profitable, low-stress podiatry housecalls practice, you can reach him directly at 415–308–0833 

Do I Need an Office for Podiatry House Calls?

No.  And seriously...why would you want one?

To be realistic, lets look at what you get when you decide to set-up a podiatry office or store-front location. You now get to pay rent. You get to pay paychecks (that you write of course, out of your own bank account) to nurses, medical assistants and office staff. 

Then of course you will need insurance, too. So you buy renter’s insurance to insure the property in the office is covered against theft, fire, vandalism, etc. You will buy slip and fall insurance to protect you from the out-of-work opportunist/scam artist who perceives you to be rich and therefore someone who might want to pay out rather than fight a frivolous lawsuit. You will need to buy workman’s compensation insurance to cover the salary of that perpetually late and/or rude employee you need to fire. And let’s not figure waiting room furniture and all of those podiatry chairs that each cost about as much as a small car. 

If spending all of you income on an office fun to you, then by all means, open a brick-and-mortar podiatry office.

But if you plan on doing house calls, keep in mins that all of those expenses will cost you, even while not use...as in all the time you are out doing house calls. 

If your brick-and-mortar office overhead expenses run at $100 per hour than you have to make $100 per hour every hour while out of the office just to cover the office expenses. 

If your total office expense are more like $200-$500 per hour, better drive fast. 

When you eliminate all of that useless office overhead, it suddenly becomes much easier to make a real profit doing podiatry house calls. 

I am not trying to contend that office setting aren’t useful for most practices. I am only pointing out that when you choose a podiatry practice model based on direct pay, house calls and increased physician access, an office is a lability and not asset.

The podiatrist who believes he needs an office in which to see “serious cases” such as infections, diabetic emergencies and the like, is fooling himself. Serious cases don’t need an office, they need a hospital. 

Think about an urgent issue that a podiatrist discovers in a nursing home. The Podiatrist doesn’t take the nursing home patient back to the office...he treats the patient right there, or admits the patient to the hospital. 

This certainly more closely follows the course of a podiatry house call practice. 

You certainly need to consider whether or not your target market is really patients who want to visit an office for care, or patients who want to have their care delivered to them at home. 

If you think your market is BOTH, you will likely find little success in either. 

Choose wisely, but choose one. 

Dr. Christopher Segler is a podiatrist who started a house calls based podiatry practice from scratch. He designed an insurance-free practice model that works and is profitable much earlier than a conventional podiatry office practice model. After working out the kinks, you has shared his recipe for house call success with a limited number of podiatrist. If you are considering building a house calls based podiatry practice, and wonder if it would work for you in your community, you call reach him directly at 415-308-0833. 

10% of Docs Expected to Stop Taking Taking Insurance in Next 3 Years!

If there was ever a great reason for the timid to start a concierge podiatry practice, this would be it.

A recent article in Forbes discussed reasons why so many docs are planning to go insurance-free in their practices. It is not just fed-up, frustrated and overwhelmed primary care doctors. The AMA says it is across the board. All medical specialities have doctors who now believe running a practice free of third-party insurance reimbursement hassles is the most profitable and best way to go.

An independent research firm claims 9.6% of all doctors plan to switch to direct-pay models of practice in the next 1 to 3 years.

If you are a podiatrist who has historically relied on a group of primary care providers to funnel patients into your waiting room, this is good news.

Birds of a feather...

If you are the only podiatrist in your area who accepts NO insurance, you are the obvious best referral option.

Concierge docs are often viewed as forward-thinking independent risk takers. However the reality is that they aren't really taking big risks eliminating slow-paying third-party payments. They get paid immediately and consistently. The accounting is much simpler. The profit is higher. Life is better.

All of the decreases in time spent on the business side translate into increases in time on the patient care side. There is more time to research new procedures and better techniques. There is more time to respond to patient questions and make podiatry house calls for patients in your practice.

When a podiatrist opts-out of Medicare and stops taking insurance, the primary care doctors all know you are going to provide a higher level of attention than someone who is worried about reimbursement issues based on low-paying insurance contracts.  This alone would be reason enough for them to begin referring their clients to you for podiatric care.

So if you have been thinking about making the switch from a high hassle/low reimbursement model to a low-overhead/high satisfaction podiatry house calls practice, now would seem to be the time.

Dr. Christopher Segler used to take Medicare and insurance. But one day he woke up. After of years enjoying his podiatry house calls practice model in the San Francisco Bay Area, he has been approached by podiatrists all over the country asking one simple question, "Could a house calls based podiatry practice work for me in my area?" And the answer so far, in every case, has been YES! He now often helps other podiatrists set up and get their house calls practices started. If you have a question, you can reach him directly at 415-308-0833. You can view his practice websites at AnkleCenter.com DocOnTheRun.com and LaserToenailHouseCalls.com

Top 10 Reasons to Start a Podiatry House Calls Practice

There are many advantages of a house calls based Podiatry practice dependent upon your particular lifestyle.

1. Extremely Low Overhead.
In fact, when compared to a conventional podiatry practice there is almost no overhead. There is no rent to pay. There are no employees to pay.

2. Absolute Freedom and Flexibility in Scheduling.
This is perfect for people who like to spend time with their children, exercise,

I once had lunch with another Dr. who asked me, "Do you really answer your telephone when you are running?"

I explained that I do. He said, "But doesn’t it bother you the you have to answer your phone to talk to patients when you’re out for a run."

I replied I guess it depends on your perspective. If I told myself that it was annoying that I had to talk to patients when I was out running maybe it would. But instead what it used to tell myself is that if I was working at Kaiser or in some other similar conventional practice model, I wouldn’t be out for a long run at 3 o’clock in the afternoon.

3. Immediate Payment.
In a housecalls based practice you’re not required to take insurance because you’re not competing with all the other podiatrists in your area. Because you do not accept insurance you get paid immediately. Immediate payment is much better than net 30 60, or 90 days… or worse yet… never. If you’re reading this and you have been in practice you understand the pain of providing podiatry care for services provided and then never receiving payment from the insurance company. It happens to everyone. It is a reality of accepting insurance. In 3 years of providing housecalls with a cash-based practice, I have never had an episode where I didn’t get paid.

4. Lower Malpractice Insurance.
Malpractice insurance carriers offer part-time insurance rates for those who do not have full-time practices. This is not based on the number of hours that you work but it is based on face-to-face time with patients. I currently see about 1/9 of the patients that I used to see in a conventional practice. My malpractice insurance is based on one quarter time. It is also paid at about one fourth of the rate.

5. The Best Podiatry Office in the World.
I routinely post pictures that I take while I’m out on house calls. The vast majority of the podiatry offices I have ever been in are dark enclosed boxes. Many of them are in the basement. Even those that are relatively nice, can't hold a candle to the views that I see when I’m out treating patients. It is much better to take in the views all day long.

6. Variation in Routine.
I like the idea of driving around town and going to different settings all day long. It probably doesn’t hurt them in one of the most beautiful cities in the world. However if I were in any city in America, I would still prefer to do house calls to and sit in a dark claustrophobic office. I like the variation of seeing different parts of town all day long.

7. Increased Job Satisfaction
There is absolutely no question that a house calls base practice model allows me to use the full knowledge that I have acquired through years of school and clinical practice. I get to interact with patients in a meaningful way where I actually apply everything that I know.

This was simply not true of a conventional practice. I had treatment protocols that were applied to the most common conditions when I had a practice that accepted insurance in an office setting. I have a large staff that was trained to take over many of the functions that I is a physician would provide. Patient education was provided by protocol by the staff.

I now perform all physician functions myself. This ranges from taking the full history to making a diagnosis to providing patient education and explaining the treatment plans. I feel like a real doctor again. I used to feel like an assembly line worker. I’m able to actually stop and think about what is really going on with a competent patient. I don’t just offer them one treatment and then tell them to come back in a week or two. We talk about "if this, then that" possibilities. We talk about all sorts of scenarios that could unfold based upon how their treatment is evolving. We talk about different recovery options.

All of this is what I initially perceived would be my job when I decided that I wanted to be a doctor. Today my practice is exactly as I wanted to be.

8. Gratitude From Patients.
Although I only see about 1/9 of the patients I used to see, I receive about 10 times as many thank you letters. Believe it or not I actually receive tips. I have had patients that even sent more money than I asked for. I had one surgical patient that actually paid me $100 extra in cash on the day of his surgery just so I would “do an extra good job.” No insurance company ever sent me a tip. For that matter no insurance company ever sent me a thank you letter either. Although it is not my primary goal, it is nice to feel appreciated.

9. Higher Income
If you have a practice the grosses $500,000 per year it sounds like you’re making a lot of money. If your expenses happen to be $400,000 per year, you’re not making a great living at all. In fact you’re making less than the average podiatrist in the United States.

If you have a house call space practice and you earn $200,000 per year, with almost no overhead at all, you’re making significantly more money. After all, the goal of work is to earn money to facilitate the lifestyle that you choose.

10. Time with Friends, Family and for Other Interests.
When you have a house calls podiatry practice with significantly lower overhead and immediate payment for services provided you have a lot more freedom.

If you don’t want to work on the weekend you can charge more to work on the weekend. If you don’t want to see patients in the evening you can choose to either not see those patients or you can see them at a much higher rate. Earning significantly more money during these more lucrative windows of opportunity allows you the freedom to spend time with family or pursue other interests.

A side benefit that many don’t consider is that when you have a practice with multiple employees high rent and other expenses you are probably less likely to take a vacation simply because you know will cost you thousands of dollars.

When I go on vacation now I no longer worry about paying 7 employees to sit in the office on Facebook, while no income is being generated. In fact, I often schedule remote consultations while I’m on vacation so that I can continue to generate income and follow-up with patients even while I’m sitting by the pool in Hawaii. That’s not a joke. I have actually performed consultations for patients while on vacation in Hawaii while my son is playing in the swimming pool.

When I had a conventional practice, I took very few vacations and all were based around podiatry conferences. Last year, I went to Houston twice to visit my sister, I trained for and competed in an Ironman race, I went to Portugal, I went to Los Angeles, I went to Las Vegas, I went to Washington DC, and I went to Hawaii..twice.

This year I’m training for and competing in 3 Ironman races. I will also be visiting my brother in Phoenix twice. I’ll be visiting my sister in Houston twice. I’ll be spending a couple of weeks on the French Riviera. I’ll be spending a month in Hawaii. I’ll be going to Miami to visit friends. I’ll be vacationing in Mexico as well. I will go to Las Vegas. I’ll go to Los Angeles a couple of different times also to visit friends.

This amount of time away from work would have been unthinkable with the limitations of a conventional practice.

Dr. Christopher Segler is a podiatrist who previously practiced podiatry in a conventional insurance-based high-volume surgical podiatry practice, which he started from scratch straight out of residency. He became increasingly frustrated with the long wait for payments from insurance companies, insurance denials, massive overhead, and administrative hassles of running a conventional office-based podiatry practice. He then converted his practice into a low overhead, high profit house calls based podiatry practice. Today it is his mission to help other young practitioners and frustrated long-term podiatry practitioners develop the freedom of lifestyle that allows them to have significantly higher income with more fulfilling patient physician interactions in a much more profitable practice model. He has even written an entire Podiatry House Calls How-To Manual to help other podiatrists start a house calls practice on their own.

Podiatry House Calls Practice How-To Blog

This blog will help you understand everything you need to set up your own highly profitable housecalls based podiatry practice. This practice model is feasible whether you're in a large city or a rural community. You just have to figure out whether or not this practice model is right for you.

If you are reading this, you likely fall into one of 2 groups.
1. Practicing podiatry for years and worn out with practice.
You have been practicing podiatry for many years and have recently realized that the high-overhead of a conventional practice is barely profitable when excepting continually and persistently decreasing reimbursement rates for your services paid by insurance companies.

2. Just getting ready to start a podiatry practice.
You have been working hard through residency and you have learned virtually everything you need to know to care for a patient... except how to set up a podiatry practice. You've heard about podiatry house calls and have decided that that practice model might be right for you.

Regardless of which of these 2 groups you may fall into, the chances are good that a podiatry housecalls practice might be the best setup for you.

I have created this blog in order to help others learn how to set up a low-cost, high profit practice that has the potential to generate significantly more income than the average podiatry practice while working a fraction of the hours.

In the coming posts, you'll learn all the details of this practice model. If you are thinking about setting up a podiatry house calls practice and have a question, you can simply post it as comment. I will post and answer as a reply as quickly as I can.


Dr. Christopher Segler is a podiatrist who previously practiced podiatry in a conventional insurance-based high-volume surgical podiatry practice, which he started from scratch straight out of residency. He became increasingly frustrated with the long wait for payments from insurance companies, insurance denials, massive overhead, and administrative hassles of running a conventional office-based podiatry practice. He then converted his practice into a low overhead, high profit house calls based podiatry practice. As a result, he sees approximately 1/9 of the patients he used to see while significantly increasing his income. Today it is his mission to help other young practitioners and frustrated long-term podiatry practitioners develop the freedom of lifestyle that allows them to have significantly higher income with more fulfilling patient physician interactions in a much more profitable practice model.