Leasing Office Space for Dental & Medical Practices

Entering into a lease agreement for your dental or medical practice is one of the most important decisions and agreements that you enter into for your practice. There are both financial and non-financial terms that should be properly negotiated to protect your rights; these are complicated and convoluted terms that should not be negotiated by a novice.

Many times landlords try to sneak in a language in lease agreements that gives the landlord the option to move your office from one location in the building to another, or worse yet terminate the lease by giving you a couple months of notice. Equally unfair and oppressive could be a language regarding your rights as a tenant if the landlord decides to sell the building and the new owner wants to demolish the building. These terms could mean that after you make a large investment in the premises, the landlord could ask you to move to a new office or even vacate the building, and if you have signed a lease agreement that provides the landlord with such an option then your investment in building a suitable office for your practice and patients could simply go to waste.

A different but a related topic is whether you have an option to renew the lease. However, just having the option to renew does not mean that you have negotiated the rent for the option period and the new increased rent may be cost prohibitive for you to stay and render your option period essentially meaningless. You want to maximize your investment in the lease premises and avoid wasting it for a short-term lease, not to mention that it will be more difficult to sell your practice if you have a short period left on your lease as you will need the landlord’s cooperation to extend the lease which is something that just about any sophisticated potential buyer will require. Clearly in those situations the landlord will have the upper hand unless you have foreseen this situation and negotiated a lease that deals with it before it ever comes up.

You also want to be weary of terms in the lease regarding what is considered a breach and whether you have a right to cure the breach; otherwise, you may find yourself in breach of the lease followed by hefty fines and penalties and even the possibility to have to vacate the premises. These provisions also give the landlord the chance to look for excuses to hold you in breach if they want to get rid of you because they want to bring in a tenant that will be more lucrative for the landlord or if the landlord wants to sell its property to a buyer who wants to revamp or rebuild the building and you happen to be in the way.

Whether you are concerned about who pays the build out cost for the office space for your medical or dental practice, whether the landlord can simply move you from one office to another office after you make substantial and costly improvements to the premises, whether you have an option to renew the lease, or who is responsible for repairs, or a plethora of other terms regarding Breach and/or Default, you should have proper legal representation to protect your interests and tens of thousands, if not hundreds of thousands of dollars, that you invest in your office space. Feel free to contact me (301-309-9002; ask@dentalmedicalattorney.com) if you are seeking experienced legal representation in negotiating a lease for your medical or dental practice.

A. Shane Kamkari, Esq.

CounselForDoctors.com

Medical Care Nusce

Anti-Kickback Statutes Definition for Dentists Physicians Chiropractors & Other Medical Professionals

The Anti-Kickback statutes are codified under 42 U.S.C. § 1320a-7b. In short, these statutes stand for the proposition that it is a crime for a dentist, a physician, or a chiropractor to knowingly or willfully offer, pay, solicit, or receive remuneration, directly or indirectly, in cash or in kind, in exchange for, referring an individual, or furnishing or arranging for a good or service, and for which payment may be made under Medicare or Medicaid. The Anti-Kickback Statutes are similar to Stark law, however, one of the main distinctions is that while Stark law does not have an intent (to commit the act) requirement, the Anti-Kickback statutes do.

“Safe Harbors”

The Anti-Kickback Statutes and regulations contain several “safe harbors” and other parameters for dentists, physicians, and chiropractors for establishing compliant relationships –including the need for “fair market value” compensation. These safe harbors are:
a- Personal services
b- Space and equipment leases
c- Sale of a medical practice
d- Practitioner recruitment
e- Employment agreements
f- Others

Failure to meet a safe harbor does not make an arrangement illegal for a dentist or a physician but it may be investigated and prosecuted. While many Stark exceptions bear similarity to the Anti-Kickback safe harbors, most Stark Law exceptions applicable to practice acquisitions and physician employment have fair market value and commercial reasonableness requirements, including the bona-fide employment exception, the personal services arrangement exception and the fair market value exception.

Feel free to contact me (301-309-9002; ask@dentalmedicalattorney.com) if you are a dentist or physician seeking legal representation for business healthcare matters.

Have a Strong Advocate on Your Side!

A. Shane Kamkari, Esq,

Medical & Dental Practice Attorney.

Exit Strategy for Retiring Dentists Physicians Chiropractors & Veterinarians

Are you a retiring dentist or doctor? Do you have an exit strategy for when you want to retire?

I meet more dentists and physicians these days that have let their practices go sideway because instead of having an exit strategy they simply reduce their workload by reducing their number of work days and patients. They virtually could not do more harm and injustice to themselves and the value of their practices that they worked so hard to build up except for outright closing their practices or tearing them up with a chainsaw.

By reducing their workload and number of patients not only are they significantly lowering the selling prices of their practices but they are also making it nearly impossible to sell their practices at all. A buyer who is willing to pay a premium in form of the selling price is looking to take over a viable practice, not one that they have to work hard to rebuild and revive. Couple that with the fact that the selling price is based on the practice’s gross revenue and/or net profits and you will realize that without an exit strategy you will stand to lose hundreds of thousands of dollars, if not millions. If you are a dentist or doctor that is planning to retire the time to plan your exit is about 2-4 years before you actually want to retire, not on the eve of retirement. There are a number of options that allow you to plan ahead and retire without losing the value of your practice so you can better enjoy your retirement.

But even if you have already reduced your workload, number of patients, and/or your revenues, due to my experiences as medical and dental practice attorney and by devising out-of-the-box strategies, I can offer you options that will help you regain most or some of the value of your practice. Feel free to contact me (301-309-9002; ask@dentalmedicalattorney.com) if you are a dentist or doctor expecting to retire and you are looking to maximize your selling price.

Have a Strong Advocate on Your Side!

A. Shane Kamkari, Attoreny-at-Law

 

Start Up of a New Dental or Medical Practice?

If you are a dentist, a doctor, a chiropractor, or a veterinarian and you have the entrepreneurial spirit that helps you thrive in business settings and dealing with the business aspects of running of a practice, then there is little downside to owning your practice. Once you answer that threshold question, the next question is whether you should buy an existing practice or start a new practice of your own. There are pros and cons to both approaches, and this article will discuss the most important factors in deciding whether you should start a new practice from ground up.

Starting up your new medical or dental practice provides you the opportunity to implement your own vision of how you would like to run your practice. This includes creating the work environment that you always envisioned, hiring and training employees that you believe will best suit your future practice and patients, the type of services that you would like to offer to your patients, and whether you want your practice and patients to be more insurance or out-of-pocket oriented.

Another obvious advantage of starting your own dental or medical practice, as opposed to buying an existing practice, is that you have the option of picking the location of your new practice as well as the demographic of your patients based on business surveys and analysis that include the population growth and other trends in your desired locations, the cost of leasing or buying office space, and a location that is both more convenient for you and fits the vision of the practice that you plan to run. If you decide to buy an existing practice, your options with regard to the location of your future practice is limited by the practices that are in the market and then further limited if you find a location that you like but the purchase price is overpriced or simply above the range that you are willing to pay to purchase a medical or dental practice.

Another advantage of starting up a new medical or dental practice is owning new equipment, software, furniture, etc. You will be spending a substantial amount of your life in your office so it will be much more rewarding if you feel at home and are comfortable there, not to mention that with brand new equipment you will not have to worry about fixing and repairing older equipment and the cost and headaches related to them.

The biggest disadvantage in starting up a new practice is obviously having significant overhead and paying the costs and expenses of running your office and practice while you don’t have any patients on the first day you will open for business or not having enough patients for months after your grand opening. You should therefore anticipate that and have enough funding in place to survive between 6-18 months. In my opinion, this is not as significant of a factor as it once was because more and more dentists and doctors build up their practices and patient-base by signing up with various insurance companies and becoming part of networks where patients find you or are referred to you. Due to the dental and medical industry becoming more insurance-oriented, the length of time that you need to survive with fewer patients is therefore shortened; of course, this also depends on your field of practice and the more specialized you are the longer and more difficult it becomes to be fully booked.

The other concern that I don’t necessarily consider to be a disadvantage is the flip side of the coin in that whenever you start and embark on a new project or business, you lack experience in various aspects of running that business even though you were well trained in school for treating patients. Depending on your personal preferences, however, there are a lot of material that you could study and learn how to develop business systems for billing and communicating with patients, hiring and training employees, and other aspects of practice management. If you are not one to do your own research and learn from books and videos, you can certainly hire practice management consultants that are experienced and can help you catch up in these areas; you just have to consider that as part of your budget and funding.

If you are considering starting a new dental or medical practice, I can help you with all aspects of starting your office whether it is obtaining your permits and licenses, negotiating a lease or purchasing office space, purchasing new dental equipment, introducing you and/or supervising contractors with expertise in building out dental and medical offices, and companies that will assist you with your insurance credentialing, and other aspects of starting a new practice and establishing a patient-base that will help you grow and succeed. Feel free to contact me (301-309-9002; ask@dentalmedicalattorney.com) if I can be of assistance in reaching your professional goals and objectives.

Have a Strong Advocate on Your Side!
A. Shane Kamkari, Esq.

Finding The Right Attorney for Your Medical or Dental Practice.

There are a number of questions that you should ask yourself and consider when embarking on buying or selling a medical or dental practice. There are likely hundreds of thousands of dollars, if not millions of dollars, at stake depending on the size of the practice, and the attorney that you choose to represent you plays a major role in the success of your transition in or out of a practice.
The ADA Center for Professional Success has issued an article titled “A Dentist Guide to Selecting A Lawyer” that provides excellent guidance on choosing the right attorney. As part of this article, the ADA lists some questions that you should ask your attorney to see whether they have the required knowledge and experience in handling these types of matters and to see if the lawyer is the right fit for you; these questions are:

“(a) Are you experienced in this kind of matter?
(b) Will you be the lawyer handling this matter, or will an associate be handling this?
(c) How long do you estimate it will take to complete this matter?
(d) How much do you estimate your services will cost me?
(e) What is your fee structure?”

These are all valid questions to ask, but the article further emphasizes that you should also consider the attorney’s reputation and communications practices with their clients. Please keep these considerations in mind because transactional attorneys that handle buying and selling run-of-the-mill businesses do not deal with issues that are specific to buying or selling of medical and dental practices and they are not as adept in healthcare transactions as an attorney that is experienced in this field.

Whether you are interested in buying or selling a practice, I highly recommend that you contact an attorney even before contacting a broker or an agent. First, as a seller, you will be entering into a legally binding contract with the broker and you should have legal advice before signing the broker’s contract. Also, it is common that the buyer of a practice will informally discuss some parts of the contemplated transaction and tacitly accept terms and conditions without knowing that those terms could have far reaching consequences both financially and legally. Even if the terms do not become legally binding, they create expectations in the other party that become difficult to overcome in the course of negotiations.
Feel free to contact me (301-309-9002; ask@dentalmedicalattorney.com) if you are contemplating buying or selling a medical or dental practice and I am happy to answer all of your questions and then some so you can decide whether I am the right attorney to represent you in one of the biggest transactions of your professional life.

Have a Strong Advocate on Your Side!
A. Shane Kamkari, Esq.

Medical-and-Dental-Practice-Attorney-for-Stark-law

Medical and Dental Practice Attorney for Stark law

Stark law is applicable to any dentist, physician, and/or medical practice that accepts Medicare and Medicaid patients. It prohibits dentists and physicians (the definition of which includes chiropractors) from referring patients to any facility where the practitioner and/or their immediate family own, are invested, or have an interest, for certain “Designated Health Services” (“DHS”). In addition to penalties for the referring dentist or doctor, Stark law also prohibits the referred facility to bill for services rendered for such DHS. There are certain services that do not trigger Stark law, and there are also exemptions and exceptions that may be applicable under certain circumstances.

 

Designated Health Services (DHS) Under Stark Law.

The following is a list of some of the DHS that are regulated under Stark Law:

  • Clinical laboratory services
  • Physical therapy services
  • Speech-language pathology services
  • Radiology, radiation therapy services
  • Durable medical equipment and supplies
  • Occupational therapy services
  • Parenteral and enteral nutrients, equipment and supplies
  • Prosthetics, orthotics and prosthetic devices and supplies
  • Home health services
  • Inpatient and outpatient hospital services
  • Outpatient prescription drugs

 

Penalties under the Stark Law.

  • Denial of claim: must refund any payment
  • Civil monetary penalty: $15,000 per claim, possible triple damages
  • Failure to report: $10,000 per day
  • Exclusion from Medicare and Medicaid programs
  • Civil law, strict liability with no “intent” requirement
  • Excluded from Federal Health Programs

 

Attorney for Dentists Doctors & Chiropractors.

With a wave of relatively new federal and state statutes that regulate the dental and medical industry as well as the entire medical industry being in the spotlight from the law enforcement perspective, it is imperative that you, your practice, and your contracts are in compliance with these rules and regulations and that you are properly represented by an attorney that is experienced in this field of law.  Kamkari Law offers legal representation in the following commercial healthcare transactions:

  • Buying or Selling Medical and Dental Practices
    “Partnership” and Buy Into Medical and Dental Practices
  • Start-Up of Medical and Dental Practices
  • Buying or Leasing Office Space for Medical and Dental Practices
  • Associate Employment Contracts for Dentists and Physicians
  • Litigation of Commercial Disputes Including Breaches of Contract and Partnership Lawsuits

Feel free to contact me 301-309-9002, 202-309-1156, or ask@dentalmedicalattorney.com to schedule a consultation for an attorney regarding these commercial healthcare matters.

Shane Kamkari, Esq.
Attorney-at-Law
Lawyer for Dentists Doctors
And Other Medical Professionals

What is the transition period?

Transition period refers to the length of time that the selling dentist or physician agrees to stay onboard and be employed by the buyer after the Closing. Depending on the type of practice this may be a very important part of the negotiations and contract including the length of transition period and the compensation paid for it. The importance of the transition period stems from the fact that the buyer does not want to meet the patients of the seller without any introduction by the seller that normally comforts the patients and is a conduit for the patient to return to the office after a nice introduction.

Many patients may not have the incentive to return to the same office once a new dentist or doctor has taken over and having the selling dentist or doctor that is well familiar with the patients and is willing to give a nice introduction to the buying dentist or doctor goes a long way to increase the chances of the patients returning to the same office in the future. For the same reason, the transition period plays a big factor in determining the purchase price. A selling dentist or a doctor that has no intention of returning to the office immediately or shortly after the Closing could lose a great deal of leverage in setting the purchase price.

As previously mentioned, a factor in determining the purchase price is the predictability that the buying dentist or physician will have the benefits of certain amount of revenues and/or profits which could be substantially affected if the selling party is not willing to return to the office for a specified amount of time, the transition period. The parties must also negotiate the compensation for the selling party throughout the transition period that may trigger Stark and/or Antikickback statutes.

The structure of transaction: Should you buy the stocks or assets of a practice?

It is rare when a buyer or the buyer’s attorney would or should accept structuring the deal as a stock purchase (when the seller is a corporation) or interest purchase (when the seller is a limited liability company LLC). The main reason is that in stock purchases usually all the previous liabilities of the corporation or company are automatically transferred from the seller to the buyer, whether said liabilities are known or unknown.

When you purchase the stocks of a shareholder in a corporation or an interest of a member in a LLC, you are stepping in the shoes of the previous shareholder or member from whom you purchased the stocks or interest; therefore, the corporation or the LLC remains the same entity that had the previous liabilities and you will now be holding the bag as the new shareholder or member of the same old corporation or LLC that carries these liabilities.

There are also tax consequences that should be carefully considered in deciding how to structure the deal. Conversely, in an asset purchase, the buyer usually remains liable for certain liabilities that s/he accepts to be responsible such as the remainder of a loan for certain equipment or other contracts that buyer expressly agrees to adopt; otherwise the contract should include a language that avoid all other liabilities. The above is not an exhaustive list of the pros and cons of structuring a transaction as a stock purchase versus an asset purchase and it is highly recommended that you have the benefit of legal counsel for taking any action that may be cause severe irreversible damage to you.

What are the various stages of transactions for selling or buying dental and medical practices?

The first step is obviously finding a practice for sale that is well suited for you; that includes the location and size of practice, the seller’s demand for purchase price, and your over all goal and objectives. Once a suitable seller is found, the process starts with sending a letter of intent to the seller or the seller’s agent which expresses your interest in purchasing the practice. The letter of intent should include both binding and non-binding provisions. Generally speaking, the non-binding parts of a letter of intent include the business terms such as the structure of the deal, whether you are interested in buying the stocks or assets of the practice, the purchase price, any offers of employment, etc. Until and unless you are satisfied with the business records, tax returns, the legal due diligence, and other matters, you should not make a firm offer to purchase the practice. Throughout my practice I have been surprised by potential clients that contacted me after having sent a letter of intent themselves, without the input of an attorney, believing that anything and everything in their letters are non-binding only because the letter states it is a letter of intent. A letter and its terms do not automatically become non-binding only because a letter states it is a letter of intent and a seller may be able to force you to follow through and purchase the practice based on a letter of intent that does not specify it is non-binding. The binding terms usually include a “no-shop” provision by the seller and non-disclosure agreements (NDAs) that protect the confidentiality of the seller, the buyer, and the information and documents that are exchanged by the parties.

After forwarding a letter of intent, the seller usually makes the necessary disclosures that would give the buyer a window into many aspects of the practice so that the buyer can determine the terms that s/he is willing to offer to the seller. These transactions normally include intricate negotiations over many weeks and sometimes months regarding the business and legal terms that will affect both the buyers and sellers for years to come. These negotiations are usually done by exchanging offers and counter-offers in form of elaborate contracts until both parties feel comfortable signing the contract. Your attorney should conduct and complete business and legal due diligence that may differ in scope; the risks involved and the cost of completing such due diligence and your comfort level on accepting the risk are some of the factors in deciding to pursue a certain line of inquiry. Once due diligence is satisfactorily completed, the parties will proceed to the Closing.

What are the different roles of the attorney that will represent you in selling or buying a practice?

Your lawyer should not only be experienced in general commercial transactions law but there are major and serious healthcare statutes such as Stark and Antikickback laws that affect selling or buying a practice unlike the transactions for selling or buying a run-of-the-mill business; your attorney should therefore have solid knowledge and experience in selling or buying of dental and medical practices.

In many transactions your lawyer may also be your advocate and negotiator in negotiating the business terms including the purchase price, the transition period, and any compensation paid to the selling dentist or doctor during that period.