Tea Nguyen, DPM (00:54.072)

I want to welcome Amanda Hill, who is the owner of Hill Health Law Group. And I thought it's about time for us to hear from legal counsel on what we need to be aware of when it comes to building our practice and maybe some employment contracts that might be relevant to those of us who are building the practice but are also seeking employment or have employment, things to talk about. So welcome to the podcast.

Amanda Hill (01:18.648)

Thank you. I absolutely love talking to doctors and podiatrists and this is my world every day and hopefully I can help give you some nuggets of info for your listeners.

Tea Nguyen, DPM (01:27.426)

Yeah, I've seen you all over LinkedIn and you've been on other podcasts and I'm just very curious about your exposure to direct care. Is there a difference between what a private practice that takes insurance versus one that doesn't take insurance? Are there any considerations or is it all kind of the same thing?

Amanda Hill (01:45.226)

Say it's like apples and oranges. They're very separate in a lot of ways. I mean, first of all, in a traditional insurance practice, especially if you're a special t specialist, you hang a shingle, you know, you get credentialed, people come in, you need a pr you know, biller, someone in house or a contract. And that's sort of the way it's been operating for the last, you know, bajillion years. And now all of a sudden we're seeing all these DPC practices, all these cash pay concierge practices that used to be for the rich and famous, and now they're for everyone.

And it's a huge shift in my world to see so many doctors going out doing direct care than there ever has been before. But it's surprising because they think, gosh, I don't have insurance. Now my life is gonna be easy, right? Now I don't have to worry about all those complicated rules. There's no Medicare, there's no, you know, commercial audits. And then they think it's just gonna happen overnight. And one thing I always say is like it's still a business.

And if you don't have a performer and a marketing plan and you know you don't think about it like a business and you're solving people's problems, you're still gonna, you know, be crying at the end. So you still have to think about it like an actual business with employees with you know issues. So I think they're very different. And I would say probably marketing is a lot more important when you have a direct care practice because people are shelling out, you know, a pretty sizable membership fee or cash pay.

versus just charging the general insurance. We have a backward system of medicine where people have you just used to paying twenty five dollars a copay and now you have to really re educate them right on what you're actually

Tea Nguyen, DPM (03:22.89)

It's so offensive. Twenty five dollars, come on. It's offensive.

Amanda Hill (03:26.007)

It's offensive. Yeah, and we did that, right? We America created that system. And so now we're like, wait a minute, we have to redefine what this looks like. So it's a different focus.

Tea Nguyen, DPM (03:35.512)

Yeah, and with the insurance type of practice, there's a lot more volume, which means there's a lot more exposure and liability. Compared to concierge, which I want to be able to clarify here, concierge is a hybrid. It's, you bill insurance and you have a retainer. And that was initially intended for like the one percent of people of a certain income. And then direct care steps in as DPC or DSC. And for DPC, their motto has always been to be affordable with monthly membership options. 

And then we've got DSC, who we don't really have longevity care per se. People don't really need us year round, depending on your specialty. And so we're selling packages instead. So there's a little bit of nuance when it comes to direct specialty care. But nonetheless we are less dependent on insurance reimbursement. So I was just very curious to understand how you've dealt with practices like that.

Amanda Hill (04:31.52)

Well, I mean, you have to refocus your energy on my liability is not gonna come from the area of, you know, malpractice rates just go down. I mean, they do. When you're spending that kind of time with people and you develop a relationship in a membership model, you know, and you have fewer patients, the odds are that you're gonna develop a stronger bond with them. And so malpractice is not your primary concern. Also, you're obviously not gonna have to spend money and time dealing with audits, you know, from commercial payers and, you know, all the fraud and abuse laws that are typically in play. 

But it doesn't mean there's no legal risk. You know, you are still a business, you still have employees. And if you hit the magic numbers of certain statutes, then certain laws apply. You know, you can't get away from having people work for you just because you have a different structure of how patients pay you. And so if you're going to have over 15 employees and someone gets pregnant and they want to go out an FMLA, or if you have to fire someone, you know, these are all routine questions that I get every day from

my direct care clients, right? They're like, wait a minute, I thought I could just start this company and it would be easy. And all of a sudden I'm having to fire a front desk staff and she's causing me a c I you know consternation and she's going to the workforce commission and I've got an EEOC complaint. And I, you know, they just forgot that they're really are running a company. And so you have to be cognizant of the laws that apply, you know, across the nation, no matter where you are, in what state you're in, you know, how many people work for you.

And if you're over 15, a lot of laws are triggered, like FMLA and the 80, you know, Americans with Disabilities Act and certain laws that are triggered on certain numbers of employees. So if you've got five people working with you, you know, it's it might be one analysis. If you've got 20 people that end up working for you, you know, there's other things to consider. But anytime you're working with people, as we all are, you know, then you're gonna have issues that pop up. There's conflict. Right. There's risk management. There's things that you have to really still address. and I love talking about employment law because to me that's just people solving people problems. And it doesn't really matter what kind of medical practice you run.

Tea Nguyen, DPM (06:35.704)

And it doesn't ever run out.

Amanda Hill (06:38.486)

Yeah. I know, right? It doesn't.

Tea Nguyen, DPM (06:41.166)

Very interesting though, because I have not heard of a direct care practice that have more than 15 employees. I think we're in kind of a gig economy where we are contracting with part-time workers, virtual assistants. So I'm wondering what your perspective is on how we manage things that maybe we don't know. Are there things that come up when it comes to this type of practice where we're contracting with like upwork, freelancers? internationally, what kind of issues arise for the doctor?

Amanda Hill (07:13.4)

Well, there's still the basic things of, you know, do you have a lease that you have to negotiate? Right. Are you going to have a brick and mortar store or is it all telemedicine? Sometimes people do still have brick and mortar. They want to come in and do a DEXA scan. They want to make sure that they meet with people face to face, you know, in their practice. So you have to negotiate leases and things like, you know, there's an air conditioning issue. You gotta work that out. We all have vendors, no matter if you're primarily online or not, right? That you're gonna work with. And what are the contracts look like with those vendors?

You know, do are they going to hold on to any of that responsibility for their services? Are they just gonna fade into the ether? If you hire a marketing company, right, which is a huge marketing lift for a lot of you, then what does the contract look like and how do you get out? I preach about this all the time to doctors, and I'm sure if you read LinkedIn, talk about it, which is you have to find every single contract, and this isn't just contracts with your providers, but vendor agreements. Where's the back door? And if they suck.

No offense, but you got to cut them off. And how do you do it? And a lot of doctors forget about that. And they just sign things through DocuSign, like, yeah, this is great. They're gonna increase my revenue. They're gonna do all this marketing, make all my TikTok videos, gonna be fabulous. Then three months in, it's not working, and they have no idea that they've signed a six month or a year long agreement and what the the notice period is vague and they're not sure how to get out of it. Now they're stuck with all these fees. And so it's really important to still negotiate contracts.

Even if it's a marketing contract, you know, or it's a telehealth platform or your email or whatever your situation is, you still have to negotiate contracts and think like a smart business person and not just sign things. You know, all of us are putting our real money on the line when we start these companies. You know, it's not, it's not invisible money. And you're getting a business loan oftentimes and the the runway is like running out. So you have to be able to cut these things off if they're not working for you. And that's probably one of the biggest areas of risk.

For one a new doctor that's kind of like, yeah, has a small staff and really trying to be lean with hiring contractors. They either get in too far, you know, in too deep financially, and then they go, uh-oh, I'm not making the money that I thought. These membership models aren't working, I don't know what to do. Or they get over their head on a vendor agreement, they don't know how to get out of it. That's another big one. You know, there's all kinds of small business issues that pop up. And it's just you need to just stop thinking of yourself so much as

Amanda Hill (09:41.024)

a physician and start thinking, I'm a small business owner. You know, a small business is gonna go through these hiccups. It also you need staying power and you need to stay motivated and people like you giving each other, you know, encouragement like this podcast and then telling each other the tips on you've got this, you know, you can do it. We need you out there because doctors are getting burned out left and right. They're done, they're fried, they want to go do something else. And we need them to stay in the business and do these kinds of practices.

Tea Nguyen, DPM (10:08.366)

That's a good point about the contracts. I fortunately, knock on wood, haven't had to deal with a contract. I had to leave because you always want to know the leeway. So that's one of the questions doctors need to ask. How do I get out of it should I have to? Not that you intend on bouncing around, but marketing I think is a big one where maybe you sign on a marketing contract where they manage your Google SEO and things. Right. I don't really know what those contracts look like. I know I've had one, but I've always asked, is this month to month?

Or is there like a retainer? So that's such a good point. Same thing with virtual assistants too. Have you had have you encountered companies where they hire out virtual assistants that have these longer duration contracts?

Amanda Hill (10:51.862)

Have seen almost every type of contract that you can imagine. And it's okay to go month to month, you know, if you want to really limit your exposure and say, I just want to see if this works for a little while. Others, yeah. If you're using a marketing firm, especially a local marketing company, they will want to lock you into a longer arrangement. If you do something like Fiverr or, you know, short term agreements, they're usually pretty transactional. You know, I want this Google ad, I'm paying you for this one thing, and then you're done but also I think just because you're a small business doesn't mean that you don't have to think through, should I hire someone as a 1099 or as a W-2? You know, I mean, when you get more established and you're thinking, all right, I need a medical assistant, right? I need a front desk person in my space. How do you hire that person? You know, that is an analysis that you need to go through. Are they going to be under my control? Do they have certain hours? You know, are they independent? Can they just take any old time off?

Or do they have to take certain days in advance and give you notice? All of those questions determine on whether they're truly a contractor or whether there really should be a W-2 employee. And if you get that wrong, then your state workforce commission will tag you with a bunch of unpaid, you know, back payroll taxes.

Tea Nguyen, DPM (12:07.52)

Is that state dependent?

Amanda Hill (12:09.91)

It's state dependent. Yes. So every state should have, you know, the kind of their own analysis on, for example, you might say, look, I don't want any employees. That sounds like a headache. Everybody that I hire is going to be a contractor. And then you go, but I want a front desk person that's at my actual clinic location every day from eight to five. You have to give me notice. You have two weeks of vacation. You can't have both of those things concurrently. If you control their schedule, if they come every day, if they're under your control.

The state is going to interpret them as an employee, whether you call them something else or not. And so you're liable for back taxes for not paying payroll taxes to them if they go to the workforce commission in your state and file a complaint. So those are things that doctors don't ever think about. You know, another thing I see a lot is doctors are like, okay, I'm starting this new cool practice, but I need side money hustle, right? I want to get a side hustle that makes money while I'm doing it. So they pick up a locum gig or they pick up a medical directorship or a number of other things.

You have to make sure that you don't get into something that you regret. You know, if what if you got into a medical director agreement that slapped a non-compete on you? You know, what if you sign something that binds you to something that you didn't even realize? Like, wait, I'm just supervising this nurse practitioner over here for a little extra side money. I I'm not going to be responsible for their med spa. That's insane. Well, you are responsible because you signed this agreement saying you were responsible.

Tea Nguyen, DPM (13:34.558)

Do you read the agreement?

Amanda Hill (13:36.48)

So I don't think doctors sometimes realize what they're getting into. They're just like, it's only a thousand dollars a month. I'm not, I'm not gonna take responsibility or ownership. And I'm like, well, you are by the fact that you're their supervising physician, you know, and now they are reporting to you and you need to review their charts, you need to meet with them monthly, you know, all that. So if you're gonna do a side hustle, you need to make sure you understand the risk that you're taking on. And I've had doctors tell me, I'm not signing that medical after I talked to them and I read the agreement, they're like, I'm not signing that medical director agreement for that home health center or that hospice group because it's not worth it. It's too much on me when I leave this job and have all these non-solicitants and restrictions. So it's just really important that you don't just leave your illegal brain at the door just because you're opening up a direct care practice.

Tea Nguyen, DPM (14:24.108)

Yeah, that's a really good point. A lot of doctors who start their direct care practice, they want additional income revenue. And I heard a saying where it was the faster the money, the more risk is involved. I don't know if that's a common thing to hear or say. And I think that's kind of where we get caught up is you know, our debt load is so huge that we are quick to grab the next dollar, whether it comes from a patient or another job. So I want to kind of lean into the potential risks that doctors expose themselves.

two when they take on whether it be another 1099 or a W2, probably more like a ten ninety nine where they're independent with their free schedule. What should they be really looking at when they're trying to find additional revenue or money? Or what are the circumstances that exist for them?

Amanda Hill (15:11.97)

Sure. A lot of doctors, I mean, gosh, they come from various different backgrounds. Let's just say a doctor wanted to pick up shifts at like an ER, if they have that training, which, you know, if that's their thing, they're working in a hospital system as an ER, maybe PRN, and yet their direct care practice, they have opted out of Medicare. Right. That could be a conflict because you've opted out of Medicare in your private practice, but you're trying to use your MPI in this other context where you can't opt out. So those things need to be thought through.

You know, what type of job are you working? Is it okay? Are you using the group's NPI or your NPI? Did you opt out in that context or not? Another one is that doctors are the recipients of scams. I mean, anytime you sign your name to say, I agree, you know, I, Dr. Nguyen, you know, is signing my name that this patient needs to go to this rehab facility or needs to have this surgery or this direct, you know, DME, you're responsible for that signature. And

Doctors are being preyed upon by these companies. They're like, all you have to do, you know, we have it all set up for you. You just sign here and then we'll get you basically it's free money. And you should always have your hair stand up a little bit on the back of your head when you hear you don't have to do anything. Money just starts coming in. That is a red flag. You know, they're using your name for something. And if you don't really know every step of the plan that your name is being used for, you easily get wrapped up in a scheme.

And I've seen it countless times. I had a doctor once that got and and again, you don't know their scams. These are very sophisticated vendor relationships. They're online, they have websites, they have emails. You know, this isn't some sketchy thing where it's like, you know, some gobbledygook email and like half of it's were spelled wrong, you know. And so you think, this is cool. I'm gonna all I do is review this chart and make sure it's appropriate for them to, you know, get this certain therapy.

And I get paid for it. Boom. Easy. Well, then you realize it's actually a Medicare scam, right? They're wanting your prescription power to then re report to Medicare that you have seen that patient and cleared them for some surgery, whatever that didn't actually exist. And by the time you catch it, they are gone. You know, the vendor, this alleged vendor is a scam artist. They are often international. They have taken, you know, they've paid you something so you don't feel like it's a scam because you're getting a check, you know, every month.

Amanda Hill (17:36.77)

But by the time the government finds out about it, it's really too late. And guess who's responsible? You. You're the one that lives in America. You're the one that has the NPI number. And so I just think doctors are easily convinced that something is some is a good deal and then they're so lured by it. And especially if a lot of their friends are up doing it, that is, you know, it's not intentional. But every single time you get involved in something where you just sign your name or have a prescription and you get paid, you should probably have a healthcare lawyer look at it.

Tea Nguyen, DPM (18:05.996)

You want to know what grinds my gears. Yeah. And doctors say it's just a blank. It's just a visit. It's just a prescription. It's just a referral. And I'm like, unless your malpractice is free ninety nine, it's not just anything. It took us at least eight to ten years to have the privilege to hold that. And we're held to a higher standard. And our liability is higher. So Right Right.

It's never just in anything. So I'm so glad you pointed that out because it's easy to get lured into what seems really easy and then all of a sudden you're on national news. Yay.

Amanda Hill (18:43.006)

The thing that comes up a lot is just the overhead. Doctors are very different on what they believe they need in overhead. Some doctors go crazy and I'm like, you need to calm down. You don't need a one million, three million as your insurance coverage. You know, you barely have any patients and you need to slow that down and get much smaller limits. You know, or you don't need a cybersecurity policy. You don't need to have all these people doing, you know, they they they come from the world of a hospital

And they feel like overwhelmed, like they must have all of these things. Well the Risk exposure

Tea Nguyen, DPM (19:14.818)

 Yeah. All the risk exposure. We're constantly being reminded that everything's a risk. You misdiagnose something or you mistreat something. It's a r you people die and all the things. So we are hyper. I don't think we're hyper vigilant in the best way. I think we're hyper vigilant in a way that harms us ultimately.

Amanda Hill (19:33.528)

Sometimes it's true. And sometimes it's the irony that the lawyer is saying, You don't need that. You know, you're overcovering yourself. You know, have a small patient base at first and really work on building the trust with them. Because that is going to beget more patients and more word of mouth and focus on quality marketing, solving problems. You know, some of the direct care practices fail because they jump in and try to make too much money, too much money too fast. And then they're like, I thought this was a panacea. I don't have to deal with insurance. I thought I was gonna make a lot of money. It's still hard, you know, at first to try to build your base and get your name out there. There is a lot of hustle factor, but it's also kind of exciting because like this is such a new landscape and so many people are entering it now. It's not as like you said earlier, it's not elitist like it used to be. And so it's kind of like a fun new era where we're like, hey, this is a new world. We get to actually tap into this. And everyone is becoming more used to membership models.

And paying those kind of fees. It's not as scary. So you're gonna get more clients and it's just a really fun time to be in this world.

Tea Nguyen, DPM (20:38.68)

Think so. I mean, I was we were just talking before we recorded this has been going on This podcast has been giving weekly episodes for like four years now. I've lost count. And it's just there's always something to talk about or something to reiterate because you know, we forget. and there are new things when it comes to legal issues and laws, especially. And that's not a topic I talk a lot about on the podcast because it just seems to change and be very state dependent.

So are there some I don't know, some universal truths that doctors get wrong or overlook that you think doctors need to know like today, right now, since they're listening?

Amanda Hill (21:18.444)

Well, first of all, I'm very honored that I'm a lawyer on your podcast. So thanks for having me. That's so fun. I will say that doctors universally think that they can jump into a hybrid space too fast. So they start with direct care. They like the model. They love it. Like, I'm free. I don't have to deal with all those problems. Then they get a little pinch point where they start to feel the pain. They don't get as many patients as they want. They wish they were making more money.

And then they immediately want to say, okay, fine, I give, I cave. I'll just accept insurance. That can get tricky. Okay. Because all insurance contracts, even though they the contract itself is short, they all have provider manuals buried in the interwebs somewhere. You gotta go dig out. Every one of them does, you know? And there are certain rules on what you can and cannot do as far as membership fees, concierge charges, extra benefits that you're gonna give their patients. Do you have any idea what those are?

So don't just go signing up for Blue Cross, you know, without having a clue of what their rules are, because it could be that the rules in that pay and this doesn't state, doesn't matter what state you're in, these contracts are pretty similar state to state, is they're gonna have rules that say, I'm sorry, you can't charge a membership fee for that. And you're like, Of course I can. I'm doing it right now. But if you sign up and have a contract with those companies, then you're violating that contract. And then you get in trouble and then they tell you you can't, and you have a big fight. So before you flip to hybrid, it's not a casual discussion. You need to really think it through before you try to think, I can have the best of both worlds. Because often you have to stay in your lane for a little while and make sure that you really know what you're offering, the benefit, the pricing, get all that down. 

And there might be an opportunity for you to be a hybrid practice, but it's not a casual discussion. You have to really know what the plans say. And I would probably do that before you do, before you flip the switch. You know, know what you can and cannot you know, carve out. And then it has to be very clear to patients. This is not a covered service. It's never gonna be a covered service. You agree to pay. I mean, the amount of content I write in a day, I mean, it's astounding. The fact that you have to overcommunicate to patients. So they will not go file some deceptive trade practice or a better business bureau or Yelp Review or the hundreds of ways that

Amanda Hill (23:41.24)

People come after doctors. And the worst is when they go to the licensing board. You know, what a stab in the heart because you're having some billing dispute with a patient and they go to a licensing board at you. So you have to be really careful that you communicate to them this is what this money is for. This is what it's covered and not covered. You know, these are the rules and this is kind of what you're getting. And I think that it's doctors assume that patients understand that and often they don't. So you have to be pretty clear.

Tea Nguyen, DPM (24:09.454)

Glad you pointed that out because I just had this exact discussion with another what were they? Some kind of insurance thing. I was asking them specifically how does MD VIP actually works? And the conversation was the exact same. Cigna, for example, they have a clear declaration that if you're contracted with their insurance, you cannot charge them a membership fee. That's a violation. But Medicare doesn't have that.

So you wanna make it very clear that if you're going to provide a cash service that it's a non-covered service. Right. But realize also sometimes that can change. They can decide one day, now we're gonna cover it. Yep. Or they can say that was a non covered service, but we're gonna have a clawback and we're just gonna dip right back into your bank account, withdraw it without your approval because you already signed away the contract that says we have the right to do so. Plus they're the government. So they're just gonna do whatever they do. 

Amanda Hill (25:05.774)

So I just met with a doctor like a couple of days ago and we called it our pep talk. I didn't even charge her. She's like, I'm like, look, let's ch I just feel bad. I'm gonna sit with you and talk to you about your direct care practice. And I convinced her not to go hybrid because of that reason. I was like, you have to stay so on top of these rules. They will cover a service in a minute, but that doesn't really mean they pay you. It means you get two dollars and fifty cents for whatever the heck it is. You know, but because it's they call it a covered service, then you can't charge for it anymore. I mean it's a constant.

Amanda Hill (25:35.32)

dance of trying to catch what the changes are and what the rules are. So, you know, if you're brave enough to go direct care, really try to do it, you know, before you just give up and say, okay, fine, I'll go get credential with all the payers. Because the freedom is worth it if you can get the marketing right and get the solve the problems. You know, but you just can't hang a shingle. I think people are confused by that. Like, well, I'm a doctor. I mean all I need to do is just

put something in the paper and people will find me. And that's not the way it works in any business. I don't know why you think it's any different in healthcare. You know, you have to make your connections and go beat the pavement and give free talks and, you know, have a niche. A lot of these practices too are so generic that people are like, what do you do? It's called, you know, wellness, health and longevity ink. You know, Id what what is that? And so they need to know like we do weight loss or we focus on

you know, foot problems or we do this. And you have to really target specifically what you do and to make it very accessible. And that's where you really have to hustle and just beat that into the ground. It's a lot of work, but it can be so worth it.

Tea Nguyen, DPM (26:47.662)

I just have to say I didn't. I did not pay Amanda to say not to do a hybrid. I'm just

Amanda Hill (26:53.006)

I know you didn't. I'm sorry.

Tea Nguyen, DPM (26:54.722)

I too have very strong opinions about a hybrid because it's a lot of work, a lot of work to navigate the gray waters that continue to change. Whereas if you're a hundred percent insurance free, you are a hundred percent free. Period. 

Amanda Hill (27:13.686)

I mean I agree with you on that. There are some practices that can manage it, but usually what happens is to be honest, they're an established insurance practice. And then they seem to carve out a few things that are not covered and they kind of have a membership model for that. But they go from that direction. That's a lot easier. It's harder to go from direct care and then start taking insurance because, like you said, and then you got to hire a biller and deal with the denials, and you're back into that other world. And you were you did this for a reason. Sometimes I want to tell I love doctors. Like that's my bread, my world.

My mission field, all I do is talk to doctors. And I want you all, whoever's listening to this, to feel finally like you've got your life back. You know, it's so empowering to see a doctor truly shine and feel like this is all worth it. I love my job. I don't dread going to work every week. I don't have to take that owner's call. I make enough money to live. You know, all of us are so afraid about losing money. You know, we're not gonna make it. I have to work for the group because I won't make any money.

I'm like, you make money in your brain. You're always gonna make money. You know, you just have to be creative about it, not signing random scam contracts. But you know, really getting out there and hustling. And if the joy is there and your passion's in it, I mean, patients are gonna find you. It just takes a little time, you know, and getting the right team. And sometimes you have to pivot. I have pivoted many times in my career, which I'm like, okay, I tried that. That didn't really work. I'm going over this direction, but it's not a failure.

You know, just because you have to kind of slightly shift your focus or maybe do something different than you didn't originally anticipate in your practice. So I mean, I think it's really important that we don't lose faith. We have to keep going and try to do what fuels us.

Tea Nguyen, DPM (28:56.696)

There's also a when you do a hybrid, there's also a change in the psychographic, the type of person that chooses your practice to. So I don't want doctors to lose sight that that's a marketing problem now. You know, if you're gonna take insurance, they're gonna expect to pay very little. And that's and there's a whole episode about that. We can talk about that another time. So anyway, now that we've cleared the air about the hybrid situation, you can do it. There are ways, you know, but

Predominantly your life will be more free without it. But also legal structure wise. So I wanted to know what is your all-time favorite topic to talk about with doctors?

Amanda Hill (29:37.868)

Me negotiating. I'm like a negotiation ninja.

Tea Nguyen, DPM (29:44.504)

So tell us what we can negotiate that is often missed.

Amanda Hill (29:49.226)

Okay, so when I I don't care what you're negotiating. It's an employment agreement, you're hiring someone, you're negotiating as an employer, or you're doing, you know, you're on the other side of an investment deal. There is a a million things you're going to negotiate. And the number one thing is you need to stop thinking it stop thinking about yourself. Okay. Everybody when they negotiate, they think, what do I want? What do I want to get out of this? What are my top things? What do I need to redline? What are they, you know, what do I need to assert as my dominance and leverage?

That's the backwards way of thinking, which is so cool. When you are negotiating, it's all about the other side. What do they want? What are their goals? What are they looking to build? What's their perfect employee or their perfect world? And you literally have to brainstorm what they want? And then how do I match every one of those to the closest possible way? And so when you start reshifting the way you negotiate, you're just solving the other person's unmet needs.

And they're like, they feel like, how did you know? Like you this is exactly what I want. And yeah, of course I'll make some of these changes that you're asking because you get me. You see my vision, you know. So if people could negotiate that way, they'd get a lot more. Because the traditional way of negotiating is like, here is our contract, we edit it, we redline it, we submit it over to the other side, they look at it, they accept a few things, we go, okay, I guess we'll just deal with give whatever you give us. We signed it.

That's a terrible way to negotiate. You know, it's very transactional. It doesn't really solve problems. You just feel like it's like you're grinding gears, trying to get through that process. Instead, take the contract or the legal thing away for a second and just start to think, how do I provide value to that other side? What can I do for them that no one else can do? How do I help them achieve their goals? Then you tell them how. This is how I can achieve your goals. This is how I can make you money. This is how I can make you better.

And these are simply the basic terms it takes to get there. And so if we are not aligned on those terms, we can make tweaks, but they are you already got them because you're mirroring back to them exactly what they need. And they are like, this is the perfect person for us. Everybody else is dead in the water because this is the person that gets us and will bring us to the next level. And that's when you get contract debits. That's when you get more money. You know, and also don't be afraid to ask. So many doctors are so scared, you know, because they're not used to conflict. They've

Amanda Hill (32:14.562)

They fear it versus lawyers, man. That's all we do. So it didn't bother me. But you know, I'm not gonna ask for a sign-on bonus or I'm not gonna increase that. That seems like too much. They're gonna, they're gonna run away. And instead of it, start thinking of I have such a valuable place for this person to get to their needs. And this is just what it costs to get there. I am worth this because that's what it takes to help you achieve your goals. And so you don't have to shy away from it. You can s confidently assert what you're looking for as

This is the cost of this incredible value that I'm giving you. And just that mindset shift alone will get you more than the old way, which is here are my edits. And I have my lawyer who tries to justify their time creating a bajillion changes. And then you just like to pass it across the aisle and that goes back and forth for a while. And that's exhausting and it costs you money because your lawyer's just charging you by the hour to create those edits. But what is it actually getting you? You know, start thinking about it differently. If you're gonna have a lawyer.

on your table, you know, on your side here, have them work for you. And sometimes I tell doctors all the time, like, lawyers can be invisible. You can pay a lawyer to help you strategize, help you look at things, and no one has to know that we exist. We're like a shadow army helping doctors every day. You know, and so if you're going to use them, use them smartly. You know, you can still use your voice. You can still use the strategies and get what you want and get actual changes in all kinds of contracts.

But you have to have the mindset of I am giving you value and I am justify easily gonna justify that value. So yeah, I can talk about that all day.

Tea Nguyen, DPM (33:49.838)

Why were you not part of my residency training? What is this?

Amanda Hill (33:53.643)

I don't know. I'm gonna have to jump

Tea Nguyen, DPM (33:55.566)

Our training was you don't ask for, you just get what you get. You quiet down, you don't stick out like a sore thumb, or you're gonna get kicked out, like I almost got kicked out of my residency program. So they really make sure that you're checked and you're controllable and that you don't talk about money because it's easier to control a doctor when doctors can't negotiate for themselves, right? And so we go through this cycle of disempowering the physician. And then I turn over to like my besties who are

Lawyers and they're like, You got you guys got screwed. I'm like, no kidding. No. I know. So we need to partner with our legal friends and vice versa because this is such a huge topic for everybody, wherever you are in your practice, for doctors in general. Negotiating. I don't I don't know how to do that. Nobody taught me how to do that. but I always hear doctors say, Well, I want to ask

Tea Nguyen, DPM (34:47.918)

For this dollar amount, but I don't feel like I'm giving that much value. Like there's this mismatch in energy where you know you should be having some kind of baseline income, for example. There's an MGMA data set that says this is what is considered average. Right. But when doctors come when it comes down for the doctors to ask for, you know, a few thousand dollars here and there, it's like suddenly, but am I really that valuable?

Am I I don't know if I feel like I'm worth that, you know? And it's a whole thing, it's a whole shift that we have to have nationwide. It's not just one area, it's all of us to have this conversation.

Amanda Hill (35:23.854)

There's another point to that, which is some doctors go the opposite, but they're like, Well, I might as well ask for a hundred percent of MGMA because then we'll settle on seventy percent. And that can backfire. Healthcare is tricky. If you go a little bonkers and start asking for too much, right, then the group is like, Who do you think you are? A hundred and percent, that's insane. And you're you're the part

Tea Nguyen, DPM (35:44.0)

You're Replaceable.

Amanda Hill (35:45.912)

Yeah. Okay. We're just a widget to me. And so you have to really know what you're doing. You know, if you're getting paid at forty percent and you want to get up to seventy percent, then you need to again justify your value and explain how much money you're actually bringing into the practice and what you do for that practice. And the reason that the patients are coming is because of the efforts you're making and how you're different from every other doctor. And you start leverage, leverage, leverage, leverage.

Then you back it up with the data and you say and then you act like, I am not asking for one penny more than I am worth. I'm not, of course, asking for like a hundred percent, but I I certainly need to be market, which is 70%. And so if you phrase it that way, you're gonna get a lot farther. So some doctors think there's like this old adage of like, you know, aim high and settle in the middle. That doesn't always work in our world in healthcare. You know, you need to come at it with a really realistic mind of what you can actually get.

Because if you get too greedy, like I want a hundred thousand dollar sign-on bonus, they're just gonna go next, you know. But then they're like, I don't really think that. I just I was told by this lawyer to stick up for myself, you know. So they don't really have a context of what they're asking. You need to make it believable. You know, don't go crazy asking for things you don't deserve. But also you need to be confident that what you're asking for is actually legitimate. Because of that insecurity, it's really obvious to the other side that you're just kind of shooting in the dark like.

Maybe? Can I have this? You know they're like, no. And you're like, okay, you know. Yeah. No.

Tea Nguyen, DPM (37:16.92)

I think a lot of what you're saying has a lot to do with just are we even a good fit for one another? Like if we can go back and forth and have a conversation where okay, this is the value I bring, this is the budget, I think that is such a good point that it's not just I think we all think it's one sided. It's all about me, me, me. What can I get out of it without exchange? Such a good point. So true.

Amanda Hill (37:38.19)

And it's really fun to see a doctor finally, you know, stand up for themselves and feel like they have the value seen and heard. Everybody wants to be seen and heard as a valuable, you know, part of all the training they've gone through. And to feel like they have no control, to feel like they're just, you know, someone who is dispensable or disposable is a really terrible feeling, right? We are professionals and lawyers and doctors. And you want to go in there and feel like, you know, I'm respected here. I have a voice here.

You know, and when you're just told, like, shut up and take it, we'll pay you what we pay you. There's no contract renegotiation, you know, it is what it is. Then you start to just get bitter and resentful. And you're not going to be a great doctor if you live in that space. So, how do you transform it? And whether you're working with the physician coach or whether you do hire a fantastic lawyer that's gonna help you through it, whatever it takes to get the mindset to where, you know, wait a minute. So, I'm asking for an actual market, I'm not going.

asking for more than that. I have put forth all the leverage. I have stated it in a way that's mirroring my other side's objectives. And if they're a complete jerk and they reject everything, you know what? I don't think this is the place for me. I mean, you have to be able in any negotiation to think through walking away. And that's the problem. If you're not gonna walk away, then what are you doing? What do you think you're gonna get? Because everybody can smell desperation. You know, it's like just throw you know, throwing spaghetti on the wall.

Or I'm actually negotiating because if you don't get me this reasonable thing, then you're gonna lose me and you don't wanna lose me because I'm a valuable asset to you. And that mind shift just has a world of difference when you negotiate.

Tea Nguyen, DPM (39:17.644)

I love it. I have a question for you. I had enough questions for you. Last one. Okay. For doctors who are seeking legal counsel, what should they be on the lookout for where they so that they don't get schemed or scammed on? Right.

Amanda Hill (39:31.774)

Right. Ugh, lawyers. We hate them. I'm sorry. I mean, you know, there's some good ones.

Tea Nguyen, DPM (39:36.418)

Listen, people aren't loving doctors either.

Amanda Hill (39:39.214)

I know, right? First of all, there are different, you know, just like there's subspecialties in medicine, there's subspecialties in law. I mean, I don't know how to write your will. I'm not gonna help you with your divorce. I don't know anything about that. All I do is help doctors and I'm a transactional healthcare lawyer. That is my one niche. So when doctors are going at high f you know, trying to find a lawyer, don't just find any lawyer, find a healthcare lawyer in your state. And you can start by going to your county medical society. You can go to your Facebook groups.

Referrals are the best way to find a new great lawyer. People that have actually worked with that human being before and they highly recommend them. You know, all the LinkedIn, you know, contacts you have, hey, did you use a lawyer to negotiate that? Or do you have any recommendations? Yes. And people are happy to share. You know, most of the referral the work I have is through referrals because my clients tell their friends and there's some group out there and some mom's group or Facebook club or whatever, and they all come in. So ask around is my first piece of advice.

And don't just go to the big firms and the fancy websites because they're often going to be more expensive. You can get a smaller firm or a solo that is just as good. Look at their credentials. You know, have they or do they have vast experience in healthcare? If their if their experience is like that, I do some real estate and also I litigate a few things and then I do some commercial transactions and I can do estate planning and I also do healthcare. It's like, what? That's like the you know, minestrone soup of law. I mean, find someone that truly does the thing that you want, you know, whatever it is. Get the referrals, ask around. If your friends are people that you don't know and the counting medical societies don't know, ask your state medical society. They have lists every even your malpractice carrier can give you names of good lawyers. I had a doctor come to me once and they were gonna invest in this super sketchy, like

I don't even know. Like bariatric things. I don't even remember. And they went to their carrier and they were like, hey, I need to get more insurance because I'm gonna make this crazy investment, this oxygen bariatric chamber company, blah, blah, blah. And the insurance company actually said, We're not gonna give you more coverage until you get something from Amanda Hill that says that this is okay. And I was blown away. I was like, the insurance company? I don't even know who said that. And she was like, I don't know, but they gave me your name.

Amanda Hill (41:58.006)

So you never know, but ask to start putting it out there. The people that you trust. That's the number one way to get a good lawyer. But make sure it's not your cousin or some random business person that doesn't really work with doctors. Cause that will you don't want to pay five hundred to eight hundred dollars an hour to have someone who really isn't an expert. And people and lawyers sometimes will say, yeah, I do that. I've represented one or two doctors in my career. No, no. You want people that all they do is healthcare. Now the sticker shock on doctors.

I mean, the number of lawyers is high. I mean, it's like anywhere from 500 to a thousand an hour. That's a big range in fees. And often they require a retainer. So anywhere from like a fifteen hundred dollars, maybe to five thousand, you know, that's kind of a typical retainer range to where you hire a lawyer, you get engaged with their firm, you pay the retainer of five thousand or whatever it is, and then they start working and they invoice you by the hour. Sometimes if there's money left in the retainer, you get it back.

Often they just keep racking up the bills. So you have to pay attention when you're working with the lawyer. You know, you get that first bill. It's okay to look at it very carefully and say, hold on. They spent five hours looking at this one document. Like it's okay to ask, you know, hey, what was there something complex about it? You know, are we gonna happen the next time I give you an agreement to review? Is that the standard rate? You don't have to be challenging and aggressive, but just so it's okay to read the bills. You know, if I have clients that have come to me and said,

I got a bill from a lawyer that was like thirty thousand dollars. I'm like, what? You know, and they just get these random bills. There's not a lot of detail. That's ridiculous. You know, if we're gonna spend that kind of money, you need to know what you're buying. And so I never have a problem if a client, you know, needs to have an explanation on some item, yes, ask. Then again, you know, we bill pretty reasonably, so I don't give any advice, but but you know, you shouldn't be having to pay a 30 grand bill and not know what she just bought.

That's like buying a car, you know. And so I really am annoyed with lawyers that overcharge doctors. it's my pet peeve personally when I see these runaway bills, which you know, there's two lawyers on every call. And so that's what the bigger firms struggle with is they ch have so much overhead that they end up, you know, kind of charging so much more. So that's something to consider when you're a doctor. You know, the larger groups.

Amanda Hill (44:20.748)

might want to hire the bigger firms because they have different types of lawyers. But the smaller mom and pop doctors just need us, you know, a reasonable lawyer.

Tea Nguyen, DPM (44:29.718)

That's not different from insurance, you know. When you bill insurance versus you bill a direct care practice, the insurance rates are always gonna be higher, their expenses are higher, you don't know what they're billing. So patients need to be educated if they get a bill from the ER, for example, to request it to be itemized, because suddenly the bill goes down because they don't justify it. so it's

Amanda Hill (44:52.022)

Sometimes there's mistakes. Like just last month I had a client, one of my favorite clients. He said, Hey, you charged me for this review and I didn't get the review. And it looks like it was stuck in my like outbox and I guess it didn't get sent. So I was like, I'm so glad you mentioned that. And I found the email and I resent it and we're fine. But you know, sometimes mistakes happen. We're all real busy. So it's you should look at your legal bills. Don't just keep paying them because you think, you know, you're conflict averse. Lawyers are used to it. Don't worry. You can be caught, you can raise

Tea Nguyen, DPM (45:20.694)

You crave it. I bet you you crave it now.

Amanda Hill (45:22.638)

I don't know. Not in my personal life. I'm pretty drama free. but in my day job, yeah, we deal with conflict all the time.

Tea Nguyen, DPM (45:29.4)

You get paid for it. Yeah, I get yeah. Right. Imagine doctors billing for the minutes that they have to look at an inbox, answer a phone call, get interrupted. Like I think we would be so much happier. And I like to say happy doctors make great doctors. Patients deserve the happy version of us. So now you know how to negotiate. Now you know how to look at contracts and make sure you're not signing away in a scam. And what o what else am I missing here?

Amanda Hill (45:54.75)

You need to be, I think you really need to find a lawyer that you trust. You know, trust is everything. You need to find a a business partner when you're looking for a good lawyer. You know, someone that you really truly can say, I trust their opinion and I'm gonna I'm gonna follow that advice. You know, if they say, I get a bad feeling about this arrangement, I can't really put my finger on it. The agreement looks good in writing, but something is amiss. Trust their guidance on that. Just like you know, a doctor has intuition, like.

The scans are clean, but something's wrong here. You know, I just feel it in my bones. So I think when you develop a good partnership with a lawyer, you know, you can rattle around things with them and say, What do you think about this? Am I going the wrong direction? Can you help me? You know, can you give me guidance? And finding that trusted partner is everything. Because then when you do have a crisis, you can have someone that you know you can call. I think that's the thing I hear overwhelmingly most from my clients is I'm just so glad that I knew who to call.

I know your cell phone. I can reach out to you. You I got my back. You know, that means everything because doctors are feeling so alone that the world's against them and they don't have anywhere to turn. So I think trust is really important.

Tea Nguyen, DPM (47:00.27)

I appreciate that so much. Thank you so much for giving us your wisdom and spending time with me here on the podcast today. Is there a question you wish I would have asked, or do you have a question for me?

Amanda Hill (47:12.052)

I sometimes wonder what, I mean, just from a selfish perspective, like what bad experiences have people had with lawyers? I would love to get that feedback because I don't hear those horror stories on your end, you know. I hear thank goodness I found you, you know, that kind of thing. They're happy with services, but what kind of what are the bad lawyers are out there doing? I I really think we need to re-educate lawyers, honestly. And I know that sounds crazy on how to work with doctors.

So I'd love to know what they're doing wrong so I can help fix it in my industry because that's something that I'm if I consider it a mission, then I want to change the legal field and make sure that we are answering doctors better.

Tea Nguyen, DPM (47:51.63)

I feel really fortunate that I haven't had to work with a lot of bad lawyers, but also I'm only midlife. I mean, there's a whole nother few decades to go. Just with you know, and I I think if I can just make an educated guess, I think a big part of it is unclear pricing. I emailed the lawyer and then I got a three thousand dollar bill just to send just to send an email. And that goes back to doctors the way we bill. We would never bill that way, right? And so there's a misalignment.

to the value that's returned. Because what we would do like what we would do for free because we're conditioned to, just an email, lawyers with a business savvy mind bill for that. And then we're upset about it. You know, and then suddenly all of our questions, you know, now we're going to AI or we're going to whatever free accessible tool there is. Because we never understood the value of other people's time because we couldn't find the value in ourselves. So that's my best educated guest. The surprise bill.

And the lack of trust and relationships built.

Amanda Hill (48:55.074)

That's true. I I think you're right about that. And also one of the things that I didn't realize I was unique in doing was that a lot of times I'll preview to my client the email, like, I'm drafting this. I wanted you to see the tone or what I'm thinking about. I want you to see it in motion. And then I will, of course, send emails and then forward them to my clients. Like, this is what I sent. You know, you were actively involved in this process. This, let's wait to hear back. What I've learned in working with other lawyers is that sometimes they just do all of that in the background.

They're like, why would I include the client? Because they pay you seven hundred dollars an hour. That's why. So if you're not involved and you don't see the lawyer thinking it through and changing the drafts and then the final draft is sent and then you know, then you have no idea what's happening. And then you get this bill, like you said, for three hours of time, which you're like, What? So it you know, I don't know, maybe everyone does a different style, but I have found that it's helpful to include the client in your thought process sometimes. You know, not every step, but that that

Tea Nguyen, DPM (49:51.95)

Itemized process, I think, helps definitely. Because I'm going through my own attorney through my divorce. And so we get a bill at the end of the phone call or at the end of the week. And you know, what sounds like a, I don't know, two, three hundred dollar hour visit turns out to be, you know, the back-end work that we had no idea needed to happen. There was like the preparation for the phone call, the review of documents. The assistant that also reviewed the emails that I sent, because it

It's cheaper to go through the assistant than it needs to go to the lawyer. So you know, there's all of these sequence of events that we don't have the privilege to always see until we see the bill. So I think that's what's going on, is the language is just very different.

Amanda Hill (50:34.904)

You're right. You're right. And I think sometimes doctors need to know going in, like I'm in a budget for this. You know, it's okay to ask a lawyer, what is the budget that we're looking at? And I think sometimes people aren't aware that's an important requirement. So if a doctor came to me and said, Okay, I'm negotiating an employment agreement, how many hours do you think it'll take? That's a fair question. You guys are okay to ask. And if I say, Okay, is it an income guarantee agreement plus an employment agreement?

Plus, you want me to review? And they're like, no, no, nothing. Just one contract. And I'm like, okay, probably one to two hours. You have a budget, right? You can reasonably think, okay, I'm gonna budget maybe and maybe a little bit extra over that. $1,500 is probably what this is gonna cost or whatever. Versus you know, you won't ask, then you get a huge bill and you're like, I didn't see that coming. And they're Yeah, you should have known. How would you have known? You know? So it's it's budgets, and especially in a practice sale. I will say.

And this is happening in D P C as well. You know, you have this practice and you want to sell it. You've g worked it up for five years, you have an Ebida or whatever. Someone told AI told you it was worth this amount or you're all excited. You think it's a million dollar practice. And you think, okay, well, there's some I need an asset purchase document or stock purchase agreement, and AI tells you what you need, and you're like, Great, I'll get a lawyer to draft those documents and that's it. And you think you're done. And it's like five hours of time. Practice sales are a mess. And it's way more expensive than you think.

But if you don't know the sausage making, you know, you're gonna be like, Why are you milking me? These are just templates. Why don't you just fill in the blanks? You know, and it's so much more than that. So that's why it's reasonable to say what is the budget for this project? And then also, are you sure you know what your practice is worth? Because everybody over inflates the value of their practice. And then the lawyers in there are trying to tell you, Hey, I don't know if that's really the right price. You know, so it's that the budgets are everything.

Tea Nguyen, DPM (52:28.822)

Yes. Selling the practice is on our radar, probably for the next conversation, because I've been told you're you can w however you evaluate the price of your practice, it just ends up being a negotiation between the buyer and the seller. We can hyperinflate because of our sweat equity, or we can, you know, lower it come to terms that this is just the nature of the business in this time of year, right? That would be really fun.

Amanda Hill (52:54.402)

All over the map. I mean, yeah sometimes they say, Well, my goodwill alone, you know, my name recognition is worth a million. And you're like, Sure. Wait on what? What? You know, and of course, depending on who I represent, if you're the buyer or the seller, I can go either way on that discussion.

Tea Nguyen, DPM (53:08.332)

And we just talked about the ego that, you know, escapes us. And that can also happen in selling our practice. Well, thank you so much, Amanda, for enlightening us on this wonderful topic. If people want to find you, you are located in Austin, Texas. Is that correct?

Amanda Hill (53:11.446)

Yeah, right.

Amanda Hill (53:23.938)

That's correct. And I represent clients all over Texas.

Tea Nguyen, DPM (53:26.784)

Awesome. And how do they find you?

Amanda Hill (53:28.962)

Hillhealthlaw.com or you can go to my training company which is Guard My Practice. 

Tea Nguyen, DPM (53:33.89)

Guard my practice. All right. Everything will be down in the show notes. Thank you so much for joining us today. I'll catch you all next week. Take care.