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Medspa Legal & Legislation > Concierge Medical Aesthetics

I'm a PA in FL who has been practicing medical aesthetics (botox/dysport/various fillers/various lasers) for several years. I will be contacting a healthcare attorney regarding this, but I thought I'd ask here if anyone has any correlating advice or personal experiences.

What I'd like to do is start a "concierge" medical aesthetic practice ---- that is, I come to you and perform botox/fillers at your home or office. I would have no single physical location where I practice; rather, I practice wherever business dictates.

There are many concierge practices that exist for regular medical care (primary care), and providers make house calls all the time. Florida laws are very vague regarding house calls / concierge medicine in general, and I can not find any as it relates to aesthetics.

Obvious legal issues aside (working under proper supervision of MD/DO, using proper patient paperwork/informed consent forms, proper disposal of biohazardous materials.), specifically, my questions are:

-- Having no office, I assume I would list my home address on my license as my practice address (supervising MD/DO would have to as well). I wouldn't, however, want a Department of Health inspection at my home, as I won't actually be treating any patients there... Anyone with any concierge-type experience have any thoughts about that?

-- Also, in regards to record-keeping, can I keep patient files at my home? I would need to keep medical supplies at home as well... It seems strange to do that...

-- Malpractice insurance when you are practicing all over the place -- difficult to obtain?

-- May I contact day spas who can't otherwise offer medical services, and approach them about occasionally performing medical treatments there on their clients they would schedule for me that day? There is a day spa chain in my area that has 11 day spas that wants to meet with me, but I need to find out some more information to be able to present to them.
----- At first, my initial thoughts were, "How are these day spas going to market these services, as 'they' are not offering them, I am?"
----- I thought about the mobile x-ray services that come to your office. You don't have to be credentialed as an "x-ray facility" yourself if a mobile xray service comes and takes the xray for you. Likewise, I wouldn't assume these places would have to be considered a medical facility with its own medical director, as I am holding myself out to be the mobile service that comes, but retains the charts and takes them with me.
----- Do I have to personally take payment, or are there problems with the individual spas taking payment and subsequently paying me? If I take payment, I assume I can pay them some rate for the administrative work (scheduling the patient) and for rent of the room, but I probably can't partner with them saying I'll pay them on a percentage of profit, correct?

I feel like a lot of day spas would be interested in making a little extra money. They have their clients, they could fill up my schedule, and I could travel around from place to place. We all make money; we're all happy.... right?

12.12 | Registered Commenterpacfl

The malpractice carriers most likely will not cover you outside of a medical office that is how it is in NY.

12.12 | Unregistered Commentergm

How do doctors who do house calls do it?

12.12 | Registered Commenterpacfl

Thats an interesting one and there are some concerns as well. I know because I do malpractice review. Often if its a known patient there is no problem with house calls but new unknown patients pose a different problem.
The physician has to stress follow up care labs etc. The concern is for instance someone has a suspect pneumonia and they simply write for antibiotic and walk away there could be another underlying problem like a small lung cancer that if the patient came to the office had a cxr and follow up would be detected during the standard work up. The real concern is say this patient gets lung ca next year a malpractice lawyer may try to say if the doctor did a proper work up my client would not be dying now. That is why some carriers frown on home visits as well.
All of this MUST be clearly discussed with the carrier before you even start. Maybe you can find a carrier that allows home botox just as some of the docs do with general medicine. As long as the carrier knows you are doing it and writes they will cover you then all is fine but never just start thinking you are covered just because you have a policy.
The carriers in NY are almost bankrupt so now they approve or disapprove every little thing we do.

12.12 | Unregistered Commentergm

the otherr thing is we in NY always hear that FLA is great because ther is no malpractice insurance required there. Am I wrong because it is a subject that I hear about all the time that if we were in Fla we could save tens of thousands of dollara each year.

12.12 | Unregistered Commentergm

GM- there is no FL malpractice requirement for physicians. For midlevels there is. I believe for docs you can self insure with assets of $250k, but I may be wrong here, someone can correct me.

FL PA- your plan sounds great but you'll find it costly and difficult to get malpractice to cover you for home visits. This could be upwards of $10k/yr. You may also have an issue performing a medical procedure in a nonmedical facility such as a day spa. Medical offices are zoned and built according to certain standards that other non medical offices are not held to. Your malpractice insurance may deny coverage for working in this type of facility and/or you may encounter OSHA problems.

You are able to keep patient files at home in a locked office/cabinet.

I would keep the relationship with the day spa simple. If they will book clients, sell the service and all you have to do is come in and perform it then you can give them a percentage (rule of fee splitting only applies to docs, not midlevels so far as I know) of the revenue. Whatever you do with the spa, make sure it is in writing. If you can't fee split then you can pay them a fee for management services.

It's no big deal to keep supplies at your home. Just use common sense in keeping things clean, don't let your cats make a pillow out of the gauze pads, lol.

If your main practice is aesthetics then your supervising doctor has to be a plastic or derm in our great state.

Good luck and let us know what your lawyer says...

12.14 | Unregistered CommenterFL ARNP

I'm a midlevel practitioner and have been offering concierge aesthetic services for awhile. I work under the supervision of an Internal Medicine physician who is the Medical Director of my aesthetic facility. I do work out of an office, as well. I only offer Botox and light chemical peels as a home treatment. I only do fillers in the office and this is more becasue I like the client on an exam room table with good lighting for more accurate injection. Home services are only offered to repeat clients. The first visit must always be in the office.

I am covered under the medical practices insurance plan. I am not sure of the details regarding how they got me covered for home visits because the office manager and physician handled all of that, but I do have the paperwork that covers me for home Botox injections. I did have to show the insurance copany proof of certificate that I went to a repuatable training course in injectables. I'm not sure what the actual cost to them was because they cover all my malpractice insurance.

All my charting and documentation is done online. I just carry a netbook around. The only papers I have are consents which I use for all injectables. I use an Apple application on my iphone for credit card payments. All payments are made directly to the medical practice. I'm not on salary but commission. I get a "cut" of every service and product that goes out the door.

You mentioned that your work address is on your licensure. I'm a Physician Assistant too, but my work address is not anything important when it comes to my state licensure. I have never reported to the state licensing board a change in employment. My work address is the physicians Internal Medicine office and that is where all our products are shipped to and the address I use to set up accounts with vendors. I don't think vendors care where product are being shipped as long as they are getting paid. Sales reps don't deliver products much. All my products are ordered via phone or online. It comes via mail. It is probably no big deal if your home address is your business.

I do keep medical supplies at home that I need to administer Botox and peels but keep them in a large wheeled medical bag. I use insulin syringes to inject so it is no different than a diabetic having these at their home and I have a small sharps container that I carry as well. I do keep a few vials of Botox at my house in a separate dorm sized regrigerator. That would probably be a code violation but my home is not a place of practice.

I think you would have to be under a supervising physician if you are acting as a PA doing the injections. For example, and don't quote me on this, if you are a PA then decided to get a license/certificate to become an aesthetician and you are emplolyed as an aesthetician not a PA, I think you are still held accountable to the standard of a PA, even if you are acting as an aesthetician and not working under the direction of a physician. I could be wrong but I think you will have to work with a physician.

I'm not an expert on medical laws but I would think it would get very hairy when you go into other medical spas to offer your services. If the medi spa already has a medical director you would have to be covered under his plan unless that client becomes your client under a separate business with a separate physician. This would require separate charts, etc. From a personal financial standpoint, if this scenario occured you would be splitting profits between you, your supervising physician, AND the medi spa. You would be better off just working privately with a physician or at one facility. Even then, I would negotiate that you get a cut of every procuedure you do and every product you sell.
If you are being approached by a medi-spa, as you mentioned, if they do not have a medical director they will need one that you can work under.

Because you are a mid level practitioner, you will be held to a higher standard then an Aesthetician or RN. I take a quick medical history prior to injecting including allergies, chance of pregnancy, and any meds they are on. I avoid diagnosing, caring for, or treating any major dermatoligcal issues. I will care for acne, rosacea, etc. But, if I noticed an odd facial rash, or suspicious moles, or anything else on the face, lips, eyes, etc. I document them and document referral back to their family physiciin.

Good luck to you!

What electronic medical documentation system do you use?
I would be very interested in talking with you regarding this

11.29 | Registered CommenterDr C

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