Can I conduct initial patient exams via telehealth?

Each state has its own laws which means we have 50 different layers of guidance when it comes to the requirements for an initial patient interaction prior to administering treatment. After the on-set of COVID, many states adopted new laws regarding the use of telehealth. Unfortunately, there is not one specific rule that applies. The only constant is that wherever a patient is at the time of exam, is where the provider/prescribe must be licensed. From there, state law takes over. In many states, treatments can occur via telehealth, but the big hurdle is when it comes to prescribing controlled substances. Many states still fall in line with current Federal law, which prohibits the prescribing of controlled substances without first seeing a patient in person. Florida, has gone further in the progression by allowing prescription of controlled substances via telehealth, and even re-defining telehealth in many cases to require only audio interactions. Federal law, however, is in a holding pattern until next year (meaning, the laws are lax and currently exempt), allowing for prescribing of controlled substances after only a telehealth interaction, if deemed appropriate by the prescriber. It’s important to keep an eye on this before building a clinic model around it.

Do I need standing orders?

The issue of standing orders and IV clinics is fact dependent and varies by state. You have to first understand the scope of practice of the providers and then the supervision requirements fall in behind.

In Florida, APRNs, PAs and RNs can administer IV with some level of off-site/in-direct supervision by a licensed physician. Generally, an APRN and PA have authority to conduct an initial patient exam, diagnose, prescribe and then administer treatment to patients. RNs, however, do not have the same scope of practice or powers. Instead, they rely largely on physicians for authority and direction. They can, however, operate without direct supervision. This creates some confusion and gray area over how standing orders can apply.

Standing orders are generally reserved for less invasive and contained treatments. IV therapy generally falls under an appropriate use for standing orders. A physician should prepare a set of strict guidelines for when a RN can administer IV without a patient first having a detailed exam by the physician. Think, “if this, then that”. The protocol should have contraindications listed which would require further follow up if needed, or prohibit the treatment entirely. Standing orders are not really meant to displace the typical initial patient examination, although in the IV therapy world, they generally have.

Clinics and providers should seek further guidance when compounding or providing additional services with the IV therapy.

Florida’s House Bill 227

This proposed legislation provides an effective date of July 1, 2024, and seeks to formalize the procedures for administering IV therapy to patients within the state of Florida. The bill first and foremost directs the Board of Medicine, Board of Osteopathic Medicine, and the Board of Nursing, within the Department of Health (DOH), to adopt rules to implement the remaining provisions of the bill, which require the following of a healthcare provider in the industry:

  • Obtain a self-screening risk assessment questionnaire from a patient before administering IV therapy treatment to their patient 
  • Provide patients with information regarding potential side effects and risks of IV therapy, instructions on when to seek medical attention, and a visit summary.
  • Notify a patient’s designated physician when IV therapy treatment is administered,
  • Maintain a written plan for emergency care. 

Note, the bill exempts IV therapy administered in a hospital or ambulatory surgical center from these requirements.

Although many providers and already undertaking many of these compliance efforts, this proposed bill holds significant implications for healthcare providers, patients, and the broader healthcare wellness industry as a whole, and these implications will inevitably grow larger once the various professional boards become involved, as required by the bill. For quite some time, there has been a large amount of anticipation for additional regulatory measures to be presented within the industry. The introduction and passing of this bill perhaps indicates that long awaited arrival. Rest assured, the Florida Healthcare Law Firm will continue to monitor the bill’s status in an effort to keep our clients and the industry fully informed and compliant with the most up to date rules and regulations within the industry.  

How do I start an IV therapy clinic?

With the rise in interest in wellness and body optimization, many patients are looking for an edge. Where are they looking? Wellness clinics, including those that offer high quality IV therapy and vitamin injections. Starting from scratch may seem like a daunting task. Where do you start? Should you lease space or operate on a mobile basis? Should I start my own or buy an existing business? Are franchises a good way to start?

These questions are common and deserve thought-out and thorough vetting. First and foremost, you should be certain that you understand the laws that will govern your clinic in your state. Laws such as scope of practice (who can do what in this clinic, what licensure is required), supervision (are standing orders enough? Who can practice independently?), facility licensure (Does the Dept. of Health govern, or Board of Pharmacy, or both?), what are the laws for a mobile clinic?


After that, you want to address your two biggest sources of liability – employees and patients. Do you have protocols and procedures? Are there clear (and legal) employee policies in place? Are patients giving informed consent, or do your forms fall short? What about membership programs for patients, are those policies spelled out? Does your staff understand patient privacy laws?


Things can get trickier when you’re buying an existing clinic or a franchise. Here, vetting the laws becomes even more important. You have to know what is required before you buy or franchise because you become responsible, or you invest money into a business that has been operating illegally or in the gray area and your investment is at risk.
While an IV clinic can be a great healthcare business, it’s not always as simple as it seems.

What questions should I ask before signing an LOI with a DSO?

You’ve reached the point where you’re ready to sell your practice and move into a different role in your professional career. But how do you evaluate offers from various buyers, including a DSO?


Here are a few key questions to ask before you sign a letter of intent to sell your practice:

  • Is there a financial holdback? If so, what are the terms?
    • Many buyers will expect to hold back a percentage of the purchase price for various reasons. Most commonly, its to ensure that the seller performs the conditions of the transition or that the seller has been accurate and truth in regards to the representations and warranties made regarding the practice. its important to understand how you fulfill the terms to receive the full purchase price.
  • Will another doctor be brought in to support the transition?
    • If you’re ready to retire, you are going to want to know the plan to get you there. As a seller, you’ll be the key person to bridge the gap from your ownership to a new owner and ultimately, you’re the key and sole provider too. Its key to know the plan for bringing in (and choosing) a new dentist to take over the patient care as you transition out.
  • Can you speak with other dentists that have previously sold to this buyer?
    • If a buyer has made multiple acquisitions wherein the seller has remained on board for some time, they should provide some contact information for other sellers that you can speak to and ask questions. There is no better way to gauge if this is the right opportunity for you than to speak with others that previously sold.

Planning and asking the right questions is key to ensuring you find the right partner in your transition.

When should I renegotiate my contract?

As an associate dentist, its easy to get lulled into the continuous cycle of contract auto-renewals. You sign a contract, put your head down and start working hard to build a schedule, continue to educate yourself, and produce in order to justify your position. Before you know it, you’re 2 or 3 years in and still getting compensated under the same terms you signed while in school or residency. So when is the right time to renegotiate?


The answer is, it depends. It depends on your goals with the renegotiation. It depends on how well your first few years have gone in terms of production and development. It depends on the employer. More important than timing is preparation. Are you prepared to support your proposals with information that demonstrates good reason for those changes?


While timing is not the key factor, when it comes to the terms in your agreement, timing is key. For example, if the contract specifically requires you to renegotiate during specific time frames, you must abide by those time frames. This means preparation in advance and ensuring you’ve had access to production reports and additional documentation that demonstrates your success thus far. In any case, don’t be afraid to broach the subject. If you don’t ask for it, you won’t get it.

Are Your Weight Loss Program Protocols Compliant?

The weight loss industry has been around for years prior to the surge of recent interest due to the #semaglutide and #tirzepatide phenomenon. Dietitians and nutritionists were the leaders in the state of Florida creating weight-loss plans, which resulted in the state legislature getting involved. House Bill 1375, was passed October 1, 1993, the purpose of which included mandating persons who assist others in losing weight to disclose the cost of the weight-loss program, the approximate duration of the program, the qualifications of the staff involved in the program and a copy of the Consumer Weight-Loss Bill of Rights.

The law went on to exempt persons licensed as MD’s, DO’s, #Chiropractors, Podiatrists, Naturopathy, Optometry, Pharmacist, and Physical therapists from complying with the above if they give weight-loss advice or provide weight-loss services which are incidental to the performance of their profession and not a primary activity. Weight-loss program means any plan or procedure offered to encourage weight loss. Therefore, creating a treatment plan that could include the above, triggers the requirement for #compliance.

As noted above, #Nurses and #NursePractitioners are not listed as exempt. The unknown issue is, is a clinic or practice owned by a non-physician also subject to these requirements? We don’t know at the time, but we do know that enforcement and regulations are in the sights of the legislature.

The civil penalties for violation of the Commercial Weight Loss Bill are as follows:

  1. The Department of Agriculture and Consumer Services may bring a civil action in circuit court for temporary or permanent injunctive relief to enforce the provisions of this act and may seek other appropriate civil relief, including a civil penalty not to exceed $5,000 for each violation, for restitution and damages for injured customers, court costs, and reasonable attorney’s fees.
  2. The Department of Agriculture and Consumer Services may terminate any investigation or action upon agreement by the offender to pay a stipulated civil penalty, make restitution or pay damages to customers, or satisfy any other relief authorized herein and requested by the department.
  3. Remedies provided in this section shall be in addition to any other remedies provided by law.

In summary, providers and practices involved in the weight-loss space should be cautious and should stay up to date with developing regulations and previous passed regulations. The federal government and certain states have shown great interest in this space as of late.

What Private Equity Healthcare Dollars are Seeking in a Deal

The U.S. Department of Health and Human Services Office of Inspector General (OIG), has produced literature regarding their intention to prosecute private equity firms who do not conduct proper due diligence in healthcare deals. At this time, a few private equity firms have been charged in civil litigation cases for healthcare fraud related civil allegations. However, the OIG has stated that healthcare laws with criminal penalties are not off the table. How does this impact deal flow? Knowing who now stands over the shoulder of private equity, venture capital, family offices (“PE Groups”) is essential, because it dictates what they will have to look for in acquisitions to come.

Compliance with billing and coding practices should be at the top of the list for PE Groups conducting a sort of regulatory due diligence. Medicare Advantage has become an area of concern as well, as the government is aware and realizes that there is opportunity for improper billing under Medicare Advantage coding and billing procedures, also known as MRA gaming. PE Group dollars will be more than ever looking for medical group sellers who are compliant. In the past these hurdles and issues were simply used as deficiencies that effectively reduced the purchase price. A medical group seller must ensure that their structure, contractual arrangements, tax filings, compliance with COVID-19 aid, billing and coding, and internal policies and procedures are in tip top shape. The foundation to continuing revenue in healthcare is compliance, and PE Groups have learned that if a Medical Group is non-compliant, the money faucet is turned off.

Medical Groups of all sizes, from solo practitioners to thousands of providers, shall require compliance plans that are both properly followed and enforced. The need for a compliance officer within a medical practice (not the owner), is a requirement when seeking reimbursement from a governmental payor. Commercial carriers will surely follow any requirements set out by the OIG as it relates to government payor enforcement.

The DOJ has also released guidance that deal documents shall be subject to scrutiny where due diligence and representation and warranties shall be parts of the deals which are reviewed. These are the areas where a buyer and a seller can prove that proper due diligence was conducted, and if any bad acts (healthcare fraud) were discovered, it was self-reported.

The Biden-Harris Administration has released guidance over healthcare spending in the United States and has directly blamed the involvement of private equity in the healthcare space as the main driver for increased spending on healthcare. Healthcare was 17.3% of the national GDP in spending in 2022. That was a 4.1% increase from the previous year. The Executive branch is committed to curtailing the involvement of PE Groups in the healthcare sector and will continue to do so via OIG and DOJ enforcement, and Anti-Trust legislation. Before going to market, medical groups need to be aware of and prepare for the level of scrutiny that the current regulatory landscape is dictating.

What role does a lawyer play in a transaction?

A lawyer’s primary role in a dental practice transition is to protect their client’s interest, whether as the buyer or seller. Most importantly, its important for a lawyer to ensure that the language in purchase documents actually match the spirit and intention of the deal. No one ever expects that a transition will lead to litigation, but if one party misrepresents key facts, or fails to fulfill a responsibility, it can create problems post-closing.


A lawyer should also be the leader of the transaction to ensure that it moves efficiently and without interruption. A typical transaction involves at least 5 parties – the buyer, the seller, a practice broker, a lender, a practice consultant. Sometimes, it involves more than that. Each of these parties have multiple things occurring at once and while deadlines are flexible in general, lending puts the most pressure on a deal closing due to interest rate locks.


A lawyer should also be a mediator. At times, hard conversations have to occur. Whether it be about the structure of the deal, the transition period, post-closing obligations, or otherwise. A lawyer can step in to help find middle ground or the lawyer can be the “bad guy” that the client needs to use to explain a position or proposal to the other party.

Biggest Pitfalls in practice transactions 

Buying or selling a practice can be one of the highlights of your professional career. At the same time, for some, its their biggest investments while for others it’s the key to their retirement after a lifetime of achievements and success. Its not all roses, however, throughout the transaction and while ideally a transaction runs smoothly from start to finish there are a number of issues that could arise and derail a deal.

Loans and Liens

Its hugely important to ask the right questions to uncover any lingering practice or real estate loans well prior to closing of the practice sale. A late discovered loan can create a delay until the parties determine who holds the loan, the pay off amount, and if there are any liens attached to the practice.

Legal Issues

Does the practice have any outstanding or pending legal claims? This could be malpractice, employment, or even business to business. As an example, a seller might have a business name or logo that potentially infringes on another trademark. If this hasn’t been uncovered, or disclosed, it can seriously impact the deal and the transaction.

Corporate matters

Has the seller kept their corporations active? If the seller’s corporation is not in active status, this creates a hurdle to selling assets or the practice real estate. In fact, it becomes a roadblock until that entity becomes active again. As a seller, you want to ensure well in advance that your entity is in good standing and has the ability to transact business, otherwise you will spend additional time and money to bring it to order.

Lending

Many buyers seek third party financing to purchase the practice or real estate. What many buyers and sellers don’t realize is the impact and influence a lender might have on the terms of the deal and transition of providers. If there are terms that conflict with the lender requirements, this can create another hurdle for the parties to resolve prior to closing.

While these issues don’t affect every practice transition, they can certainly create a headache if uncovered towards the end of the deal (or after closing!). The key is to prepare early, plan, and do your due diligence whether you’re a buyer or seller in order to optimize you opportunities.