Business Structure:

To mitigate legal risk, “Dallas Skin Cancer Center” consists of two Texas LLCs:

  • Texas Mohs Surgery and Skin Cancer Center, PLLC (TMSSCC) is the medical practice.
  • Texas Mohs Surgery Equipment Leasing, LLC (TMSEL) is the company that owns all of the material tangible assets (cryostats, procedure chairs, furniture, computers, etc.)

TMSCC operates under the DBA of “Dallas Skin Cancer Center”.

To reduce legal risk, it is desirable for the high-risk entity, that is, the medical practice, to have minimal assets subject to a judgment creditor. TMSCC’s only potential asset for a judgment creditor is the accounts receivable. Plaintiff lawyers understand that by the time a judgment for AR is made, I would have closed the medical practice and spun up another one. There would be no AR remaining to recover. Even in the inconceivable situation where a court orders the AR frozen, I have a $120,000 debt shield, as discussed in the Financial Section.

As I mentioned above, the leasing company holds all of the tangible, material business property and leases it to the medical practice. The lease is variable and depends on tax implications. In the first years, the lease was extremely high so that TMSEL could offset the Section 179 expense (similar to depreciation). The Section 179 deduction is subject to a business income limitation, meaning the amount you can deduct cannot exceed your total aggregate taxable income.) At the time I am writing this, the Section 179 expense is complete, and the annual lease is a nominal amount to cover TMSEL expenses. TMSEL is not designed to generate income. Tax nerds will recognize the risk of the “Self-Rental Trap.” I have sent a formal letter to the IRS grouping TMSEL with TMSCC. So long as TMSEL does not experience a loss (passive), the self-rental trap is not an issue. Like TMSCC, TMSEL has a debt shield in place.

Administration:

Personnel

 

DSCC has ten employees

  • Frank Saporito, MD – Mohs & dermatological surgery
  • Elizabeth Wilder, MD – Mohs & dermatological surgery, dermatology
  • Practice manager
  • Patient coordinator
  • Four MA / histotechs
  • One MA / administration
  • Insurance specialist / assistant manager

Technology

  • Three servers

    • production

    • on-site back-up

    • off-site back-up

  • Eleven work stations

  • One computer per procedure room (four total)

  • Netgear R7000 running DD-WRT

  • Yealink phones VOIP – Nextiva

  • Servers

    • AMD EPYC

    • Asrock server MB

    • 16 GB DDR4 ECC

    • RAID 10 (encrypted) 32 GB

    • Oracle Linux 8

    • Apache

    • MySQL

    • PHP

    • Network File System

  • Work Stations

    • Ubuntu OS

    • LibreOffice Suite (open source)

The production server backs up to the on-site and off-site backup-servers nightly. There are 30 days of archives.

EMR, Practice Management Software, Billing


The practice uses OpenEMR, a medical practice management software that features fully integrated electronic medical records, practice management including scheduling, and electronic billing. OpenEMR creates the HIPAA X12 837 files that we upload to Office Ally (clearing house.)

OpenEMR is the most popular open source electronic health records and medical practice management solution. OpenEMR is free and the data belongs to you. While I run OpenEMR on my server, others deploy the software on a cloud.

Because DSCC has less than 15 clinicians, it qualifies as a small practice and receives an automatic exception from the MIPS Promoting Interoperability requirement. Certified electronic health record technology is not needed.

Accounting & Bookkeeping​

Accounting and bookkeeping are performed in-house. DSCC uses GnuCash accounting software. GnuCash is an accounting program that implements a double-entry bookkeeping system. GnuCash has capabilities similar to Intuit’s Quicken application, but also has features for small business accounting. Like OpenEMR, GnuCash is open source and free to use (no licensing.)

Payroll

Employee hours are recorded using Time Clock Wizard, which is a free online service. We us Intuit Quickbooks Payroll, which takes care of all aspects of payroll including filing forms 941, 940, W2, W3, along with Texas SUTA.