Key takeaways from this episode

• A hybrid model layers a concierge membership on top of a traditional insurance practice. Dr. Rose's nurse practitioner sees the great majority of insured patients; he does all procedures and sees concierge members directly, roughly 10 to 12 patients a day instead of 30 to 40.
• The practice still participates with traditional Medicare, which is 75 to 80 percent of its patient base. It accepts a few commercial plans (mainly Florida Blue) and only one Medicare Advantage plan, and declined UnitedHealthcare at startup.
• Concierge members still have insurance billed for every office visit, procedure and surgery at the Medicare or contracted commercial rate. The membership agreement states in writing that the concierge fee is not an insurance product of any kind.
• Membership is a one-year agreement paid monthly, quarterly, semi-annually or annually. Roughly 230 active members from more than 300 sign-ups over three years, with attrition from deaths, moves and patients who feel their problem is resolved.
• What members are buying is access and coordination. Same-day or weekend visits for retention, a suprapubic tube change at midnight in the office instead of the ER, help interpreting outside lab work and getting into other specialists quickly.
• Keep the staff lean and the billing outsourced. One NP, one medical assistant, two front-office staff, a weekly urodynamics tech, a verification and pre-authorization person, and a billing service paid a percentage of insurance and patient collections only, never the concierge fee.
• Set patient cost expectations up front. The medical assistant who schedules procedures quotes the co-pay and works with the facility on expected charges, so unhappy fee surprises are rare.
• Concierge practices in the area are all solo or two-physician, but a larger group could offer a concierge track. Dr. Rose's consultants now use his practice as the model for other surgeons; interested urologists can email [email protected].

Transcript

Lightly edited for readability; timestamps mark where each speaker turn begins in the recording. UCR 256, recorded August 2025, with Scott Painter, Mark Painter and Dr. Ray Painter of PRS Network, and guest Dr. Marc Rose.

From burned-out hospital employee to concierge urologist

[00:00] Scott Painter: On this episode, we want to welcome special guest Dr. Marc Rose to talk about his hybrid urology practice. Stay tuned. Welcome to episode 256 of the Urology Coding and Reimbursement Podcast. I'm your host, Scott Painter, with my co-host Mark Painter and Dr. Ray Painter. On today's episode we want to welcome special guest Dr. Marc Rose. He's a practicing urologist in Vero Beach, Florida, and has a hybrid urology practice. What we mean by that is it's part traditional insurance and also part concierge. Marc, thank you so much for joining us. We're excited to talk to you about this and share with our audience what this looks like, how you got started and how you're doing in this. If you would, take a couple of minutes and share with us your journey, how you got started and made this decision, and then what it looks like.

[01:00] Dr. Marc Rose: Thank you. I really appreciate being with you today, and I'm honored to be part of your podcast, believe me. I've been in practice in this area for over 35 years. I came right out of my residency and had various practice patterns: I joined one older urologist and had people come and go, different partners, et cetera, like many people in private practice. Probably 10 years ago, a patient of mine said, you know, you really should do this concierge thing. There were a couple of GPs and internists starting to do concierge care in our area, and of course all urologists would be unhappy when they would call and say, I have a patient you need to see right now, and I'm being compensated well by him and you're not. So we talked about doing a concierge thing. It never really took off at that time. My wife said, you give concierge care to people all the time; you ought to do it anyway.

I became hospital employed, like many people who would sell their practice to a hospital, and after about five years, for a variety of reasons, it wasn't working well. I certainly think I was the epitome of the burnt-out doctor. I hated to go to work. I was miserable. I didn't sleep well at night. I certainly wasn't a good family person. I didn't like myself. I think that's a very common pattern amongst doctors, certainly urologists. So when I left the hospital, I had a number of opportunities. One was to potentially retire, which I didn't want to do. My wife had me follow her around the grocery store one day and said, you better never do this again; you better go work. I thought about doing locums. I did a little bit of that. I like to sleep in my own bed at night, not somewhere else. I also was offered a position as a urohospitalist, which I thought about doing in another city, in Orlando, but that's two hours from home and I would have had to spend two weeks a month away from home.

So I thought about this concierge thing. A number of people in my town do it: a cardiologist does, an endocrinologist, and of course PCPs. The cardiologist called me and said, you really ought to think about doing this; it's been very successful for me. He hooked me up with the consultants that he used, and that I now use, and other people have used, to look at this. We gave it a lot of thought and realized it's very hard to get in to a urologist. Urologists are seeing 30, 40-plus patients a day, all the things that made me miserable. So I gave it a lot of thought, and it was a bit of a leap of faith. I talked to my wife at length about it and decided to try it, and if it didn't work, it wouldn't work. Fortunately, it's worked pretty darn well, and I've been very happy. I now love to go to work. I have a beautiful office; it's actually on the water. I have a great staff. Patients seem to be happy in the practice. I don't see 30, 40 people a day anymore, more like 10 or 12 a day. I still love operating. That's, as you always say, a very expensive habit, and I would say that for me it's still an expensive habit, because obviously fees are going down. But I am on staff at hospitals. I do take ER call at one hospital. It's not very burdensome. It's been great, and my life is a lot happier.

I work hard. I saw a patient, this is true, at midnight Sunday night in the office whose suprapubic tube stopped draining. I had to change it, but he said, to not have to go to the emergency room and sit there for hours and have somebody who didn't know what they were doing take care of me, it's well worth it. I made a house call Monday night, which is very rare. Somebody needed a catheter in and he's really homebound, so I went to his house and put it in. In the three years I've been doing this, I've probably made three or four house calls. That's it. But I'm available. When a patient calls me, I'm happy to hear from them. My wife said, you used to take call on the weekend, you'd be covering with six other people, you'd get called and you'd be miserable and throw down the phone and swear, and now you seem to be much happier. That's true. So it's been good for me. It's been good financially. I don't know who decided that doctors shouldn't make a good income, or that their income should go down. In all ways, it's been good.

How the hybrid practice is structured

Mark Painter: Excellent. That sounds great. I do remember chatting with you a little bit as you were starting out on all this, and I'm glad you were able to make the leap and find a spot. The way you're structured with the hybrid practice, you have an extender in the office who sees some of your patients? How does that set up?

[06:00] Dr. Rose: Yes. I have a nurse practitioner who has years of urology experience, so she sees the great majority of the patients, people with traditional Medicare as an example. She sees them, and people who need procedures done, cysto, prostate biopsy, stone treatment, whatever it is, she sends to me. I do all the procedures, and then we just take the insurance, whatever that is. Now, we don't take all insurances. We take Medicare and a few commercial plans, but we try to stay away from, you know, UnitedHealthcare, everybody's friend, et cetera. I talked to them when we started the practice and that wasn't going to work. So if it's a patient having a procedure, regardless of whether they're a concierge patient or not, we do charge the insurance for that. And most of those people are Medicare or Florida Blue.

[07:00] Mark: Were those your patients prior, that you'd known in your prior life and your prior working relationships, or did you actually have to start over again with all the different changes in your practice?

Dr. Rose: That is a wonderful question, and the answer is, surprisingly, a lot of it is new people. What happened was, when I left hospital employment, of course they said these are our patients, and I was not allowed to reach out to anybody and say here's where I am. Even now, a few years later, every week at least a few people come in and say, thank God I found you; I was told you retired and moved away, and here you are. So I get more and more of my old patients coming into the practice. Some join the concierge program, some see the nurse practitioner, but a lot of people are new patients. A lot are.

[08:00] Mark: Not all. Okay. And the patients that join the concierge practice with you, are they traditional patients with your practice first, or do you advertise and market and they come to you in the concierge window, and then you also let them know how the traditional practice works?

Dr. Rose: If I understand your question, people will call the office, and we have a very good front office person who explains in pretty good detail the advantages of the concierge program, but also explains to them that there is a fee associated with it, and that if they don't want to do that, they can see the nurse practitioner. I've had some people who have been in the concierge program, not too many, who have said after a while, you know, you fixed me up, I got in right away, you got me urinating properly, you did my prostate surgery, thank you very much, and now I'm going to switch to the nurse practitioner. There is some attrition, obviously.

Staffing, membership numbers and marketing

Scott: Like you mentioned, you have a great front desk person. What is your total staff size?

[09:00] Dr. Rose: I have the nurse practitioner. I have a medical assistant who works with me. We've got two front office people. We have a urodynamics person who comes in every week to do urodynamics; she's excellent. I have a wife who is the practice administrator, so she takes care of bills and all of that, and babysits me and tells me do this, do that, which is good. I need that. We have a woman who does our insurance verifications and pre-authorizations and things like that. And then we have a billing service that we pay. They take a certain percentage of collections, not the concierge fee at all, that's not theirs, but insurance or patient payments; they take a percentage of that to do our work.

Mark: Excellent. And how many patients do you have on the concierge side at this point in time?

[10:00] Dr. Rose: Right now we're at about 230. We've probably signed up well over 300 people. We've had some people who have passed away, some people who have moved away, and then other attrition where somebody says, you've helped me, I don't need it anymore. There are plenty of people, though, who say, you helped me, but I still want to do this. And I do help people navigate the muddy waters of the healthcare system. I had a man come in today who has bladder cancer, but he had lab work done by a PCP and he was worried; maybe he had a UTI, which he doesn't, but he also had me look at a bunch of lab work and I went over it with him. I will get people in quickly with other physicians and help to coordinate their care.

Mark: Very good. As you've gone through this process, have you done any marketing or outreach, or has this been more word of mouth? How have you gone about letting people know about this urology concierge practice?

[11:00] Dr. Rose: When we first started the practice, of course we put a few ads out there and we had a website, and we said, here we are, we're still here and we're doing this practice. Then when people would call, we would explain it to them. Some people who had been patients of mine for years would say, well, I don't want to change to that sort of thing. But many people just saw it, and heard by word of mouth that I was still working.

The fee structure and how insurance is billed for members

Scott: So how exactly is that set up with your concierge practice? Do they pay a monthly fee, or is it just fee for service? How does that work?

[12:00] Dr. Rose: When they join the concierge program, there is a fee and there's a year agreement. They can fund it monthly, quarterly, semi-annually or once a year. Many people do either semi-annually or once a year, and most people find it to be very worthwhile. One of the things that's happening, at least around here, is corporate medicine is charging a facility fee and an extra fee to people. You know about that, and people are up in arms about it. So many people say, wait a minute, I'm going to pay less if I pay you a monthly fee, and I can get in right away, and you're the guy who's going to put my catheter in at four in the morning at your office rather than me having to go to the ER. That's one of the advantages, and that's why most people find this fee to be very reasonable when they consider what they're getting, I think.

Mark: With those folks that need procedures who are part of the concierge practice, you're going to need to use a facility, I assume, for some of those things, and you're taking the traditional rates or insurance for the procedures as an add-on to the concierge fee. But are you not charging for office visits and those types of things, or are you charging for both in addition to the concierge fee?

[13:00] Dr. Rose: If it's a concierge patient, we are charging insurance for anything that we do. They do know, and it's in the agreement, that this is not an insurance product of any sort. So we do charge for the office visits and we charge for surgeries, but again, it's whatever the Medicare fee or the commercial fee is.

Mark: You said you help them navigate things. Do you have somebody who works with them to understand what the fees are going to be at the facility and for anesthesia and all that? Do you have to take a little extra time with those folks to give them the full lay of the land? I know one of the things a lot of patients really get upset about is all the stuff that happens on the back end, which is where the No Surprises Act came from.

[14:00] Dr. Rose: That's right. My medical assistant is very good at that. She does tell them up front, here's what our fee is going to be, you have a co-pay, whatever that may be. She schedules the procedures for me, and she does work with the facilities to try to get an idea for the patient. Plus, they often will talk to the patient directly. I've had very rare patients who have been unhappily surprised about some sort of a fee.

Who joins a concierge urology practice

Mark: Do you find that most of your concierge patients are folks with an existing urologic condition, or are they just figuring somewhere down the road they're going to need some urology care?

[15:00] Dr. Rose: That's another very good question. The answer is it's a whole mixed bag of people. I have a patient who is a retired physician from up north, whom I've never met, and he said, I just want to be in this for the security of knowing that you're available if I need you. I have another one who is a physician, a wonderful guy, a retired ophthalmologist, who said, I want to do this because I can, and I think doctors are terribly underpaid and I want to help you, so I'm going to join. I see him periodically, and he does have issues that I help him with. Then I have people, one patient was in this week, who said, I have this kidney stone and it really doesn't bother me and it hasn't for 40 years, but I just want to know that you're available if I have a problem. There are a lot of people like that who just really want to know that you're going to be available for them. And then the opposite end of the spectrum is people who really are calling frequently, and they get the care that they need.

[16:00] Mark: This is where my statistical brain runs on all this. Have you noticed there are certain problems that tend to be more concierge-focused, or is it just, as you said, a mixed bag?

Dr. Rose: I think people with a high PSA, people with a diagnosis of bladder or prostate cancer, because I see a lot of both of those. I think those are people who feel that they want this. People with stones who are worried about that. I think those are the main things you'll see people about. The other thing is people who are in retention. They've been walking around with a catheter for three weeks and they can't get in to anybody, and you say, we'll see you tomorrow. It's Friday afternoon; I'll see you Saturday at the office. And they say, my God, this is great. This is well worth it to me. Access is a big thing for people.

Scott: Have you ever had to fire a patient?

Dr. Rose: I have not fired anybody yet, and not for overuse of it. There have been a couple of people where I really didn't think it was a good match, and I told them that going forward. I said, I really don't think your problems are something that you want me for. But that's been maybe one or two people. At this point I have not fired anybody.

[17:00] Scott: With telling them that it might not be a good fit, do you select, or do you not accept, certain patients?

Dr. Rose: There are a couple of people that we know through town who have been to every urologist. They've been to me, they've been to everybody else, and everybody knows that their problem is not urological. It's supratentorial, and they need to go to the proper person.

Medicare participation, the consultants and advice for others

Scott: Ray, do you have any questions or comments?

Dr. Ray Painter: I think you've done an excellent job of explaining, Dr. Rose. From the sound of things, it sounds like you are non-participating with Medicare?

Dr. Rose: I am participating with Medicare. I am.

Ray: You are.

[18:00] Dr. Rose: With traditional Medicare, yes, I am. That's probably 75 to 80 percent of our patient base, given where we live. Now, we don't take Advantage plans, except for one that's part of Florida Blue. Otherwise we don't take Advantage plans.

Mark: I'm curious on that follow-up, and that's where I was going: how did your consultants walk you through setting this up? Was it a bit of a maze to get through, or was it fairly straightforward in how they had you put the concierge practice on top of the traditional practice?

[19:00] Dr. Rose: They had done this before with several people. They were all internists of some type or another, so I was the first surgeon they worked with. One of the consultants is actually a GP about 30 minutes from here who has been a concierge doctor for years. The other guy set him up in it, and they became partners in this business, and they are kind of the gurus of this in our area. I was their first surgeon, and in fact this has been successful enough that they asked me to work with them going forward to try to help other surgeons do this. We've had some people that we've talked to about this. So they had a formula, and we plugged it in, and it's been tweaked, that sort of thing. And the woman who does the credentialing and the pre-authorizations was very good in helping me with the Medicare number and all that. They knew about all this stuff, but she was very good too.

Mark: So it sounds like they had a fairly decent program, and now they have you and a map forward. If other people are interested in this, that might be something they could contact you about. I am curious, as you've seen it from that lens: are most of the physicians providing concierge medicine in smaller groups or larger groups?

[20:00] Dr. Rose: Where I am, they're virtually all solo. There are a couple that are two people. I don't think there's anybody more than two. I do think that if you were part of a larger urology group, you could offer a concierge track for patients. I definitely think you could do that. I just happen to be in an area where, unless you're hospital employed, most everybody is solo, or two people at most.

Mark: I imagine a piece of that for the larger group is how to actually set up the reimbursement and navigate where the overhead goes, those types of things, which is a complicating factor. It's much easier with one or two to get that all figured out. But nice to know that's an access piece.

[21:00] Dr. Rose: Yeah, I think it's been good. It's helped me to have a better life, I think. And I do think that I went into this with some knowledge myself. Some of it, I think, was just the comfort of knowing an idea about billing and coding, which I got from you and from John Lin. I never used Facebook, never looked at it, until I decided to start this practice and started looking at the Thriving Urology Facebook group, which I probably look at every day.

Mark: That's great. Excellent. It takes a village, that's for sure.

Scott: Let's wind this up here. Let's get one more question from Mark, one more question from Ray, and then I might have one more question. Ray, why don't you ask a final question and we'll get this wrapping up.

Ray: I think Dr. Rose has answered most of my questions, so I'm good.

Mark: Okay, Marc. My one question to you is, going back now that you've had this experience, would you have done this sooner?

[22:00] Dr. Rose: Yes. I would have done it sooner. I thought about it for seven, eight, ten years before that, and I was just too busy and too stressed to do it. Then I got to a point where I said, this is going to happen, and I'm glad I did it. So yes, I do wish I had done it sooner, no question.

Scott: All right. I want to circle back to what Mark asked a little earlier about advice for others. If somebody has questions and is interested in doing this, can they contact you, or do you have somebody else you recommend they contact, and how would they go about doing it?

Dr. Rose: Contact me. We actually have an email address, and it's [email protected], Marc with a C. They can email that and tell me who they are and what their contact info is, and I will get back to them and discuss it with them. I'm absolutely happy and wanting to do that to help other people.

Sponsor and final thoughts

[23:00] Scott: All right, and we'll put that on the episode page. If you go to prsnetwork.com/256, that's the episode page, and we'll put that email on there if you want to contact Dr. Rose and talk about the concierge side of medicine. We want to thank ModMed for supporting this episode. If you're in the market for an EHR or a practice management system, you can go to modmed.com/prs for specials for our listening audience. We want to thank everybody for listening today. Let's get some final thoughts, and we'll wind up with Dr. Rose. Mark Painter, start with some final thoughts.

[24:00] Mark: Certainly. As you talked to me about this years ago, it was an area that I think a lot of people have contemplated, and I think a lot of that comes from the burnout you were experiencing. The care that we're giving today, for a lot of urologists, is corporate, for lack of a better term. It's not about the patient relationships it used to be, that we used to hear about from Ray during his time as a practitioner. It sounds like you've been able to set this up to actually get back to the beginning, to a certain degree, where you're establishing patient relationships and actually enjoying your practice again. I'm sure that's something more and more people will contemplate as we start seeing these big corporate units. As we saw the other day, Cardinal has acquired and jumped into the urology market space, and we've got plenty of truly corporate approaches to healthcare right now, and some of those folks aren't really enjoying their life at this point in time. So I really appreciate you taking the time to share this with us, and I'm glad you took the leap. It sounds like it's been a great success, so I'm going to just say congratulations.

Dr. Rose: Thank you.

Scott: Ray, final thoughts?

[26:00] Ray: Well, it certainly sounds like there is a place for concierge medicine in the practice for those who are lucky enough to be in a spot and are willing to take that leap. I can share with you, as Dr. Rose has, there was a time when it was a pleasure seeing your patient, knowing you could do what you wanted to do for that patient at the time you wanted to do it, without any insurance interference. As the insurance got into the process of actually practicing medicine, indirectly, it did become less fun. So hopefully medicine will turn one of these days, but boy, it sure doesn't look like it.

Scott: All right. Let's give the final word to Dr. Rose.

Dr. Rose: Well, thank you again. Thanks for having me with you today. It means a lot to me. I would tell you that what Ray said is exactly right. We've lost the personal relationship with our patients. It's not our fault, but that's what's happened, and I feel I have it back. I have a personal relationship with a patient. It's a direct relationship, and it's great. They like it, I like it, my family likes it. My dog likes me better now, because I'm a nicer person to be around. So thanks again for having me on.

[27:00] Scott: Thank you very much. We really appreciate it. I think for those out there listening, it'll give a lot of interesting thoughts and discussions to come. So thank you. All right, that's all we have for today's episode. Take us out, Ray.

Ray: Happy coding.

Contact Dr. Marc Rose

[email protected]

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