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PPP Standing in the Way of Healthcare M&A

October 20th, 2020 by

PPP healthcareBy: Susan St. John

One of the unforeseen challenges we are seeing that affects both buyers and sellers in the health care sector is with respect to entities that have received cash infusions from the Paycheck Protection Program (“PPP”) created pursuant to the CARES Act in response to COVID-19. Mergers and acquisitions can come to a significant slowdown, standstill or be terminated altogether if careful planning is not performed to account for the impact the PPP funds received by a target or seller will have on an anticipated merger or acquisition.  While tax and legal considerations have typically followed along with the merger or acquisition and they are important aspects of any merger or acquisition, these considerations have taken a forefront position when it comes to planning for a change of ownership when the target or seller has received PPP funds.

As we learned earlier, health care entities requested and received PPP funds to sustain them during the public health emergency caused by COVID-19, allowing them to avoid a virtual economic shut-down. These funds were a welcome relief to keep health care entities afloat financially, providing a way to cover certain expenses such as a) payroll costs, b) rent, c) interest on any covered mortgage obligation (which shall not include any prepayment of or payment of principal on a covered mortgage obligation), and d)  utilities. Using the PPP funds on these expenses allows for a recipient of the PPP funds to qualify for loan forgiveness under the PPP. That all seemed like welcome relief at the time. read more

Timing Your Next Real Estate Transaction

September 25th, 2020 by

healthcare real estate

By Douglas Hughes

CARR

Every commercial real estate transaction has an ideal timeframe to begin the process. Most healthcare professionals understand that opening a new office or relocating an office doesn’t happen overnight, but the majority of professionals are not aware of the ideal timeframes for each type of transaction. Different types of problems arise when starting a transaction too early or too late, and both need to be avoided.

Too Early

If you start the process too early, it creates a scenario where you spend your valuable time looking at properties and evaluating options, working with lenders and other members of your team, only to find out the landlords or sellers won’t negotiate with you yet. Many landlords and sellers won’t take their spaces off the market for extended periods of time while waiting for the tenant or buyer to be ready to transact, because there is too much time before the transaction will actually take place.

Or if they do negotiate, they won’t be willing to offer you even close to their best terms since they are going to lose income on holding a space vacant for an extended period of time. On the other hand, if they will put forth reasonable terms, it is predicated upon you moving forward immediately, which can leave you stuck paying for a space you can’t occupy for a period of time or paying unnecessary rent on your former space if you leave early.

Too Late

read more

Prepping Your Dental Practice for Sale

June 10th, 2020 by

dental practice sales transactionBy: Chase Howard

Thinking About Selling Your Practice? Preparation is key and the difference between a successful sale and seller’s regret.

Step 1: Call Your Financial Planner

  • Be sure that you can afford to leave the business
  • Most buyers will require a comprehensive non-compete and you should be certain that you are financially prepared to retire, sell, or move before signing any restrictions.
  • You will also want to ensure that you are planning for the income you are about to receive. Are there vehicles in place or options that are best to ensure the purchase price is put to its best use for you.
  • Consider post sale options if not retirement – are you going to be employed by the buyer? Are you selling to an associate and will phase out? Are you just moving and will need to find new employment/open a practice?

Step 2: Visit Your Accountant

  • Your business is only worth as much as can be defined on paper.
  • If a potential buyer cannot make sense of your accounts and assets, you may leave significant value on the table.
  • Get your financial history in order by reviewing tax returns, profit statements, AR reports, and payroll history for prior 3-4 years.
  • Clean up creative bookkeeping – you will have to promise the buyer that your financial statements are true and accurate.
  • Have your accountant help value assets of your business – or use an appraiser if necessary.
  • Discuss company structure – there may be restructuring needs or you may need to transition to a different structure for tax purposes.

read more

Considering Compliance in Out of Network Physician Owned Specialty Hospitals

June 9th, 2020 by

florida healthcare law firm physician owned hospital compliance infoBy: Jacqueline Bain

Out of network physician owned specialty hospitals are unique in that there are less stringent legal requirements on the facility, but patient care obligations remain the same. This means that patient care must be prioritized over profits and all actions taken by the hospital and any physician investor must showcase that order of priority.

Given the amount of scrutiny placed in physician owned specialty hospitals in the past two decades, these facilities are well served to identify and implement a process to remedy compliance concerns. Even when a facility does not submit claims to any Federal health insurance provider and is out of network with all commercial insurance companies, it is still required to follow the laws of the state where it is located.

The best plan for surviving scrutiny in such situations is to have a plan. Proactively seek out applicable laws and regulations, and determine how your hospital will abide by them. Compliance can be tailored to fit your facility.

Overutilization and Self-Referrals

A physician who shares ownership in a hospital may have a financial incentive to refer patients for services if he or she receives a percentage of the revenue generated. Laws including the Federal Stark Law and Anti-Kickback Statute were promulgated to combat unnecessary referrals. A 2003 study by the Department of Health and Human Services concluded that physician-investor referrals to hospitals in which they have an investment interest are similar to those physicians without investment interests. Nevertheless, the fear of overutilization and unnecessary self referral remains at the forefront of the regulators’ minds at both the State and Federal level. read more

The Debate Over Physician Owned Hospitals

June 8th, 2020 by

florida healthcare law firm physician owned hospitalsBy: Dave Davidson

The debate over the pro’s and con’s of physician-owned hospitals has been raging for decades. Physician-owners say their hospitals are more patient-focused, provide higher quality care, obtain better outcomes and therefore receive higher patient satisfaction scores. They also point out their convenience and efficiency.

Opponents argue that physician-ownership leads to overutilization and cherry-picking of only the best patients. The less-desirable patients (both clinically and financially) are then left to be taken care of by the community hospitals. For those reasons, both the American Hospital Association and the Federation of American Hospitals remain strongly opposed to physician-owned hospitals.

Federally, the Stark Law includes an exception which allows a physician to refer patients to a hospital in which the physician has an ownership interest, so long as the ownership interest is in the entire hospital, and not just a subdivision of the hospital. However, in 2010, the federal government weighed in again on the issue, and passed the Affordable Care Act (ACA), which includes provisions which (i) restrict physician referrals to hospitals in which they hold an ownership interest; (ii) restrict any increases in physician-ownership of a hospital; and (iii) restrict expansion of physician-owned hospital facilities. CMS has granted exceptions to these restrictions, but those have been limited to rural hospitals and high Medicaid hospitals, and attempts to amend the law have failed. read more

Webinar | Prepping Your Dental Practice for Sale

April 7th, 2020 by

dental practice for saleChase Howard will present this live lunch n’ learn webinar for attendees interested in learning more about how to effectively prepare for the sale of their dental practice. He will cover issues like who and when to contact when considering a sale, proactive steps to lessen business disruption, when to tell your employees, and other important transition topics.

Preparing your dental practice for sale is quite possibly the biggest decision one can make! Understanding the legal landscape, the investment trends and options as well as what can optimize your business’ sale is essential. This webinar platform provides attendees to ask questions and chat directly with a highly qualified health law attorney.

April 22 @ 12:00 pm – 1:00 pm

Free

Selling a Medical Practice: Business Broker Listing Agreement Basics

August 20th, 2019 by

Business Broker Listing AgreementBy: Amanda Bhikhari

Many physician groups and health care companies will enter the market at some point to sell their business. In the rare case, the selling group will already have a buyer who is ready and willing to pay and close on the business sale. More often than not however, most sellers will utilize the services of a business broker to help find a suitable buyer, and will compensate the broker on a commission basis upon closing.  Unlike real estate closings, whereby the main concern is the title of the property being conveyed, medical practice sales require much more detailed representation on all aspects of the business, including but not limited to, real property, existing contracts, existing patients, and medical equipment.

Before signing a business broker listing agreement, ensure that the following points are considered to avoid potential pitfalls: read more

Thinking About Selling a Medical Practice? How to Prepare your Business

April 8th, 2019 by

selling a practiceBy: Jackie Bain

Thinking about selling a medical practice? Here are some steps for preparing your business in advance of a transaction.

  1. Visit your financial planner.

Be sure that you can afford to leave the business, if you are retiring. Most times, buyers will require a comprehensive non-compete and you should be absolutely certain that you are financially prepared to retire or sell before you sign that restrictive covenant.

  1. Visit your accountant.

Get your financial history in order. Review and re-review your tax returns and profit statements for the past three years to ensure that the business is appropriately reflected in those records. Take the time to clean up any “creative” bookkeeping so that the buyer is given a complete and accurate picture of the business they are buying into. You are likely going to have to make a representation that your financial disclosures are true, so take the time to get comfortable with that representation early on. read more

Healthcare Transactions Today: Selling a Medical Practice to Private Equity Buyers

November 12th, 2018 by

private equityBy: Jeff Cohen

Private money (e.g. private equity) is in full swing purchasing medical practices with large profit margins (e.g. dermatology). This is NOT the same thing as when physician practice management companies (PPMCs) bought practices the 90s.  Back then, the stimulus for the seller was (a) uncertainty re practice profits in the future, and (b) the stock price.  Selling practices got some or all of the purchase price in stock, with the hopes the purchasing company stock would far exceed the multiplier applied to practice “earnings” (the “multiple”).  Buyers promised to stabilize and even enhance revenues with better management and better payer contracting.  If the optimism of the acquiring company and selling doctors was on target, everyone won because the large stock price made money for both the buyer and seller. The private equity “play” today is a little different.

Today’s sellers are approaching the private equity opportunity the same way they did with PPMCs, except for the stock focus since most private equity purchases don’t involve selling doctors obtaining stock.  Sellers hope their current practice earnings will equate to a large “purchase price.”  And they hope the buyer have better front and back office management that will result in more stable and even enhanced earnings.  And for this, the private equity buyer takes a “management fee,” which they typically promise (though not in writing) to offset with enhanced practice earnings.     read more

Complicated Relationships: Medical Director Contract, Marketing Agreement, Healthcare Consulting

May 16th, 2018 by

medical director contractBy: Jacqueline Bain

Healthcare providers often have more than one relationship with each other. For instance, a physician may be employed by a hospital and also provide that hospital with medical director services. Or a healthcare consultant may also be a healthcare provider’s landlord. Oftentimes, these types of relationships are each memorialized in one or several contracts between the parties. And while, on their face, these contracts may seem to be compliant with applicable healthcare laws, when examined together, compliance and other contract issues may arise. read more