- Only 3 dermatology practices for 110,000+ people — severe supply gap
- 31.8% of residents are 65+ — nearly double the national average — peak skin cancer demand
- 6th fastest-growing county in Florida — new retirees arrive monthly needing a dermatologist
- Two AdventHealth hospital campuses with no employed dermatologist — referral pipeline immediately available
- Steven lives there and will help with site selection and oversight
- Only 3 hours on I-95 — manageable rotation without flights
- 7.3% poverty rate — minimal Medicaid exposure for our no-Medicaid model
- No Mohs surgery initially — our FLL Mohs revenue (~$25K/mo) won't replicate on day one at Palm Coast. We refer complex Mohs cases back to South FL.
- No laser devices initially — Fraxel, Ultherapy, Clear & Brilliant stay in South FL unless we transport a device monthly ("laser day")
- More Medicare-heavy payer mix — Palm Coast's 65+ population means ~60% Medicare vs our current South FL mix
- Better commercial rates expected — as a scarce specialist in an underserved market, we have real negotiating leverage with BCBS, Humana, Aetna that we don't have in over-supplied Broward County
- Lower starting RPP, growing to near-FLL levels — Palm Coast estimated $150/pt Phase 1, growing to $180/pt at maturity
Medical billing operates on a 60-90 day payment lag — insurance pays for services rendered 2-3 months prior. Our June GCR appears low in the BI dashboard because the denominator (June charges of $536K) is large while the numerator (payments received in June for April-May services) is growing but trailing. This is normal billing cycle behavior, not a collection problem. Our 23-day DSO and 97.45% clean claim rate confirm the billing operation is healthy. The strong June charges will show up as strong August-September payments.
| Provider | 2025 Full Year Payments | 2025 Avg / Month | 2026 YTD Payments (Jan–Jun) | 2026 Avg / Month | YoY growth |
|---|---|---|---|---|---|
| Dr. Matthew | $1,438,379 | $119,865 | $759,788 | $126,631 | +5.6% |
| Dr. Merrick | $654,076 | $54,506 | $333,622 | $55,604 | +2.0% |
| Dbora (PA-C) | $500,814 | $41,734 | $241,554 | $40,259 | −3.5%* |
| Three providers total | $2,593,269 | $216,106 | $1,334,964 | $222,494 | +3.0% |
*Dbora's slight 2026 dip reflects months billed at 85%. The switch to 100% incident-to billing (implemented mid-July) is projected to add ~$7,100/month and ~$85,000/year to her collections going forward. Watch her July–August payments for confirmation.
We have been billing Dbora at 85% of physician rate. When a supervising physician is physically present in the office suite, Dbora's services to established patients can be billed incident-to at 100% of the Medicare fee schedule. This applies at Fort Lauderdale and Pembroke Pines immediately, and from day one at Palm Coast when a physician is on-site. Estimated annual impact across all three locations: +$85,000/year in additional collections with zero additional work. Confirm implementation with Clarity RCM at the next billing review.
When average daily patients across all staffed days consistently exceeds 13-14 patients/day (70-75% of 18-patient capacity), a local hire pays for themselves within 3-4 shifts. At that point: local hire covers 4-5 days/week, Dbora continues monthly to maintain patient relationships, and Matthew and Merrick reduce to 1 rotation/month each. The template then replicates to the next satellite.
| Provider | Pts/day (mature) | Estimated RPP | Revenue/day | Days/mo Phase 1 | Monthly contribution |
|---|---|---|---|---|---|
| Dr. Matthew | 18 | $180 | — | 3 | — |
| Dbora (PA-C) | 18 | $165* | — | 3 | — |
| Dr. Merrick | 18 | $180 | — | 3 | — |
| Phase 1 Total | — | — | — | 9 days | — |
*Dbora RPP slightly lower as she does not perform surgical excisions independently. At 100% incident-to billing when physician on-site.
| Payer category | Est. % of visits | Avg revenue/visit | Monthly revenue | Rationale |
|---|---|---|---|---|
| Medicare (FFS) | 60% | ~$155 | — | 31.8% of Palm Coast is 65+ — our core demographic |
| Commercial (BCBS, Humana, Aetna, Cigna) | 22% | ~$195 | — | Better rates than South FL due to market scarcity |
| Cash pay / cosmetic | 18% | ~$480 | — | Botox avg $600, fillers $900, peels/microneedling $350-400 |
| Total monthly gross (Phase 3) | — | |||
Our South FL prices are appropriate for the Palm Coast market — Flagler County median HH income ($77,350) is not dramatically different from Broward. The active retiree population (outdoor lifestyle, golf, beach) is highly motivated to maintain their appearance. We should open at our standard prices but consider a 3-month "Grand Opening" discount of 10-15% to accelerate initial volume, then normalize. Do not permanently discount — it's nearly impossible to reverse and undermines brand positioning.
| Service | Our Price | Product Cost (est.) | Gross Margin $ | Margin % | Palm Coast Demand |
|---|---|---|---|---|---|
| Botox — 1 area (~20 units) | $400 | ~$120 | $280 | 70% | High — preventive injectors 45-65 |
| Botox — 2 areas (~37 units) | $700 | ~$225 | $475 | 68% | High — most common Botox visit |
| Botox — 3 areas (~60 units) | $900 | ~$360 | $540 | 60% | High — full face treatment |
| Botox — Hands/Underarms | $1,750 | ~$600 | $1,150 | 66% | Moderate — specialty indication |
| Filler — any syringe (Juvéderm, Restylane, RHA) | $900 | ~$280 | $620 | 69% | High — volume loss in 55-70+ cohort |
| Service | Our Price | Product Cost | Margin | PC Fit | Monthly volume target |
|---|---|---|---|---|---|
| VI Peel (base) | $325 | ~$85 | $240 (74%) | ★★★★★ Sun damage correction | 10-20/month |
| Microneedling (Procell) | $400 | ~$25 | $375 (94%) | ★★★★★ Best margin service we offer | 8-15/month |
| Hydrafacial Signature | $200 | ~$40 | $160 (80%) | ★★★★☆ Entry-point, drives packages | 15-25/month |
| Asclera vein injection | $600 | ~$100 | $500 (83%) | ★★★★★ Very high demand in 65+ — untapped in PC | 5-10/month |
| Aquagold | $850 | ~$200 | $650 (76%) | ★★★☆☆ Premium — smaller audience | 3-6/month |
| PRX-Derm (face) | $300 | ~$60 | $240 (80%) | ★★★★☆ No downtime — popular with active retirees | 8-12/month |
We don't need to permanently place a laser at Palm Coast to access that revenue. One Clear & Brilliant session day per month — schedule 6-8 patients at $500 each on one rotation day, transport the device — generates $3,000-4,000/month, or $36,000-48,000 annually. The device fits in a case. This is worth evaluating once Phase 1 patient volume is established (Month 6+). Fraxel is a larger device but the same principle applies quarterly.
| Service | Monthly visits | Avg revenue | Monthly gross |
|---|---|---|---|
| Botox (all areas) | 25-35 | $600 | $15,000-$21,000 |
| Fillers | 8-15 syringes | $900 | $7,200-$13,500 |
| Peels (VI, Perfect Derma) | 10-20 | $350 | $3,500-$7,000 |
| Microneedling | 8-15 | $400 | $3,200-$6,000 |
| Hydrafacial | 15-25 | $225 | $3,375-$5,625 |
| Asclera / vein | 5-10 | $600 | $3,000-$6,000 |
| Total cosmetic monthly (mature) | $35,275-$59,125 | ||
Fixed Monthly
Variable Monthly (Phase 3)
| Scenario | Monthly gross | Fixed OH | Variable OH | Monthly EBITDA | Annual EBITDA | Margin |
|---|
The EBITDA above is practice-level — it doesn't account for the fact that days spent in Palm Coast are days not spent in Fort Lauderdale or Pembroke Pines. At our actual FLL RPP of $181.56 vs Palm Coast Phase 1 RPP of $150, each provider day in Palm Coast generates approximately $560 less revenue than it would in South FL. Over 6 physician/PA rotation days per month, that's ~$3,360/month in opportunity cost during Phase 1. This diminishes as Palm Coast RPP grows and essentially disappears once local hire takes over most of the rotation days. Factor this into personal planning but not into the practice P&L model.
These are the national 2026 rates. Florida's "Rest of Florida" GPCI locality (which covers Flagler County) adjusts rates by approximately ±2-4% from national averages. Commercial payers in Palm Coast are expected to reimburse at 140-160% of Medicare — higher than our current South FL commercial rates due to our scarcity leverage in Flagler County.
| CPT | Description | Medicare 2026 | PC Commercial (est. 145%) | When we use it |
|---|---|---|---|---|
| 99202 | New patient, low complexity | $93 | $135 | Simple first visit |
| 99203 | New patient, moderate complexity | $152 | $220 | New patient full skin exam |
| 99204 | New patient, high complexity | $220 | $319 | Complex history, multiple conditions |
| 99213 | Established, low complexity | $90 | $131 | Simple follow-up — our #1 billed code in FLL |
| 99214 | Established, moderate complexity | $136 | $197 | Annual skin exam with findings |
| 99215 | Established, high complexity | $186 | $270 | Complex multi-problem visit |
| CPT | Description | Medicare 2026 | PC Commercial (est.) | Palm Coast notes |
|---|---|---|---|---|
| 11102 | Shave biopsy — 1st lesion | $68 | $99 | Our #5 billed code — high volume at PC |
| +11103 | Each additional shave lesion | $42 | add-on | Often ×2-4 per visit on elderly pts |
| 17000 | AK destruction — 1st lesion | $66 | $96 | Our #7 billed code — will be much higher at PC |
| +17003 | Each additional AK (2nd-14th) | $6 | add-on | Retirement pts average 4-8 extra AKs → $24-48 per visit |
| 17004 | AK destruction — 15+ (flat rate) | $138 | $200 | Better than 17000+17003×14 — always use when 15+ |
| 17110 | Benign lesion destruction — up to 14 | $78 | $113 | Our #8 billed code — very high at PC (SKs, warts) |
| 11400 | Benign excision, trunk/extremity ≤0.5cm | $112 | $162 | Add repair code if closure needed |
| 11600 | Malignant excision, trunk/extremity ≤0.5cm | $167 | $242 | BCC/SCC very common in 65+ coastal population |
| 13121 | Repair/closure after excision | $180 | $261 | Our #9 billed code — additive to excisions |
A 71-year-old with a history of outdoor activity comes in for annual skin check: 99214 (comprehensive exam with findings, Modifier 25) + 11102 (shave biopsy of suspicious lesion) + 17000 (first AK, liquid nitrogen) + 17003 × 4 (4 additional AKs) = Medicare payment of $136 + $68 + $66 + $24 = $294 for one visit. They return 3 weeks later for biopsy result: 99213 + 11400 (benign excision) = $90 + $112 = $202. One patient generates $496 in two visits, and they'll be back annually. This is the Palm Coast patient profile.
| Practice | Locations | Threat level | Notes |
|---|---|---|---|
| Advanced Dermatology & Cosmetic Surgery (ADCS) | 2 Palm Coast locations | Medium | PE-owned national chain. Mohs capability (Dr. Schulze). Volume-optimized, impersonal. Opportunity: be the locally-owned physician relationship alternative retirement community prefers. |
| Mid Florida Dermatology | 1 satellite (14 Office Park Dr) | Lower | Satellite of Orlando-based 33-location chain. WellMed/MA-affiliated. Their PA "Brent" is the face of the practice. Minimal local investment. We differentiate easily. |
| Parks Dermatology Center | 1 Palm Coast (multi-site regional) | Medium | Dr. Coppola has genuine patient loyalty — well-reviewed. Also offers cosmetic. Don't try to take his patients — capture the continuous flow of new retirees who haven't established a dermatologist yet. |
Broward County has thousands of physicians competing for commercial contracts — insurers have enormous leverage over individual practices. Flagler County has 3 dermatology practices for 110,000 people. When we call BCBS Florida and Humana to credential for Palm Coast, we can credibly say: "We are opening the only physician-owned, board-certified dermatology practice in Palm Coast. Your members currently travel to Daytona Beach or Jacksonville for specialty care."
That is a real negotiating position. We should request rates at least 20-25% above our current South Florida commercial contracts as an opening position. In a supply-scarce specialty market, we may actually get closer to 140-160% of Medicare vs our current South FL commercial rates which are lower due to market saturation.
| Action | Owner | Priority |
|---|---|---|
| Steven visits Palm Coast Medical Center (binaproperties.com) — report suite size, rate, current tenants | Steven | Immediate |
| Steven visits AdventHealth Palm Coast Parkway physician relations — ask about MOB space and specialist referral program | Steven | Immediate |
| Steven drives Office Park Drive — evaluate ADCS and Mid Florida foot traffic, parking, signage | Steven | Immediate |
| Call BCBS Florida provider relations for Flagler County commercial rate indication | Matthew | This week |
| Call Humana provider contracting for NE Florida / Flagler County rates | Matthew | This week |
| Dbora billing correction — implement 100% incident-to at FLL and Pembroke Pines immediately | Matthew + Clarity RCM | Immediate |
| Contact Oaklins Heritage (advised First Coast Mohs/AQUA deal) for preliminary PE strategy conversation | Matthew | This month |