Input needed on PP startup

[Ducttape]

I don't want the underqualified to kill take care of patients, or the better clinicians to be the pencil pushers.

its all about patient care for me, you know.

---

Members don't see this ad.

 

[Extralong]

If you are a block shop you can do well. If not your income will suffer. Whatever you do, don't prescribe opioids at all for anyone. The DEA told docs they are going after the top 5 prescribers in each state and will shut them down as an example of what can happen to any doctor prescribing. Their tactics have become chilling...phone taps, drones, confiscation of personal property including guns and coins, accusing docs of being potential murderers for having an old vial of succinyl choline in their house (carried home after call 8 years earlier), accusing docs of insurance fraud because they dont know the cpt billing codes for UDS off the top of their heads, etc. These were related first hand and via newspaper reports. So open your practice with all this in mind.

Can you provide the source for the following statement:"DEA told docs they are going after the top 5 prescribers in each state" ??

Just my 2 cents.:
The prescribers that are getting busted by the DEA are the ones totally mismanaging medication. It takes the DEA about halfyear to 5 years to bust a physician after they have sent in their own guys undercover. Thereafter, there is a whole burdon of proof that has to be pretty great to show that the prescriber is doing something wrong. We all know/knew a prescriber that was out of control and by the time the DEA has busted that person, we are actually NOT surprised. So, no, the DEA is not just choosing physicians that are prescribing opioids. I would caution to have an only opioid prescribing practice(obviously), BUT just completely cutting out prescribing medication to become a block shop is also not ethical. Furthermore, doing ONLY procedures screws the pain world in terms of reimbursements. Governing bodies see this as monetary abuse and start cuts. I believe that there has to be moderation. I, for example have learned to do both, and also try to get my patients in PT/OT/mental health therapy.

 

[ml2001]

Thank you all for your input. To add to the list mentioned above: Is there much difference in the negotiated rates with insurance companies between a solo practitioner vs a large group? Is this large enough that it effects your bottom line at the end of the day? One of the consultants I talked to mentioned about joining hands with a different solo practice in a different part of the state to get better negotiated rates. I'm not too excited about this as I would have no clue who this other person might be and meeting them once or twice before deciding is not a good idea in my opinion.

Anyone care to comment on this? Thnx....

-ML

 

[pastafan]

Anyone care to comment on this? Thnx....

-ML

Very state dependent but I doubt 2 docs would move the needle. Most areas have one or 2 private carriers that monopolize the market and have no incentive to negotiate, especially with a small single specialty practice. We save them a boatload of money by being office based but they just don't care.

 

[bedrock]

. We save them a boatload of money by being office based but they just don't care.

I don't understand why insurance companies are not willing to be more generous with pain docs doing in-office procedures. I did office based procedures for 5 years and saved the collective insurance companies several hundred thousand dollars. They wouldn't adjust their payments at all, even after pain procedures were bundled and their costs dropped significantly.

Currently I do out of network ASC based procedures and insurance pays a few thousand for each procedure instead of hundreds . Idiot insurance companies.

 

[ml2001]

On a different note, I'm curious if I need to buy tail coverage when I change my job if I stay with the same malpratice insurance company and get the exact same coverage?

 

[geauxg8rs]

On a different note, I'm curious if I need to buy tail coverage when I change my job if I stay with the same malpratice insurance company and get the exact same coverage?

You should be able to get "prior acts" coverage for yourself back to when you started with your (now prior) group. It will be cheaper than getting tail and starting over. You can call the insurance company without giving names , let them know your situation and they can ballpark the costs until you give notice

 

[SSdoc33]

I don't understand why insurance companies are not willing to be more generous with pain docs doing in-office procedures. I did office based procedures for 5 years and saved the collective insurance companies several hundred thousand dollars. They wouldn't adjust their payments at all, even after pain procedures were bundled and their costs dropped significantly.

Currently I do out of network ASC based procedures and insurance pays a few thousand for each procedure instead of hundreds . Idiot insurance companies.

question: why do you charge "a few thousand" for an injection
answer: because i can game the system

i know you probably dont set the fee schedule, but you are no doubt benefiting from charging exorbitant fees. this is worse than the hospitals and their facility fees by an order of magnitude 5 or 6 times.

unless i am missing something, it is a scam.

 

[Aether2000]

Source of the DEA quote: from a DEA agent discussing this with a physician in my state last week.

 

[ampaphb]

I don't understand why insurance companies are not willing to be more generous with pain docs doing in-office procedures. I did office based procedures for 5 years and saved the collective insurance companies several hundred thousand dollars. They wouldn't adjust their payments at all, even after pain procedures were bundled and their costs dropped significantly.

Seriously? You don't understand? BECAUSE YOU ARE STUPID ENOUGH TO ACCEPT THEIR RATES. Go out of network with that particular carrier.

If you are important enough in your community, they will negotiate with you. Market power is exerted not only with size, but also with customer demand. If enough of your patients let them know they will be changing carriers if you are not one of their in-network providers, they will come back to the table.

 

[hyperalgesia]

Seriously? You don't understand? BECAUSE YOU ARE STUPID ENOUGH TO ACCEPT THEIR RATES.

He has a point. If insurance paid office based pain a more competitive rate, docs would bring more procedures out of the hopd, ultimately saving the insurance company money.

I think when you're running a scam-like business model like health insurance, a lot of what you do is just to stay under the radar. If they buck the trend of Medicare by encouraging office vs hopd, they will certainly earn the attention of the hopd lobby.

 

[ampaphb]

Insurance isn't a scam, it is a business. You are under the mistaken understanding that they abide by their promotional materials. They do not. The only people they answer to is their shareholders, and their primary duty is to make as much money as they can for their investors.

Insurance companies are not in the business of saving the system money. They are not in the business of doing what's best for the patient. They are in the business of making money. If you are naive enough to think otherwise, that is your error, not theirs.

 

[hyperalgesia]

Their pitch is that they are protecting patients. It is disingenuous, which makes it a scam. The fact that people are naive and fall for it make it no less of a scam. Also, I do NOT think they abide by their promotional material. This makes them scammers also. I'm not sure where you're going with this...

 

[bedrock]

He has a point. If insurance paid office based pain a more competitive rate, docs would bring more procedures out of the hopd, ultimately saving the insurance company money.

Exactly. If they would increase their office based pain procedure pay rate by 15-25%, they would save much more by having less docs being forced to join/start ASCs or doing HOPD procedures which cost insurance 3-5 times what office procedures cost.
Insurance companies would save millions overall.

 

[lonelobo]

I would revisit this with insurers, prepare spreadsheet of your proposed bundled fee in office vs total cost at ASC or HOPD to them.
We have fortunately been able to get significant fee increases with all our private insurers this way. As a bench mark we started at about 75% of the combined facility + professional fee

 

[jsaul]

I would revisit this with insurers, prepare spreadsheet of your proposed bundled fee in office vs total cost at ASC or HOPD to them.
We have fortunately been able to get significant fee increases with all our private insurers this way. As a bench mark we started at about 75% of the combined facility + professional fee

facilty meaning HOPD or ASC?

 

[lonelobo]

facilty meaning HOPD or ASC?

yep

 

[pastafan]

How do you get HOPD/ASC non-Medicare rates to compare?

 

[DOctorJay]

https://www.asipp.org/feeschedules.html

 

[pastafan]

Those are Medicare rates not private insurers'. Depending on state these can be much higher than Medicare. We can approximate the low end of the insurer's savings by comparing to Medicare but we don't know the actual savings which should be significantly higher.

 

[lonelobo]

How do you get HOPD/ASC non-Medicare rates to compare?

I found ASC rates by asking an employee there (discretely of course)

 

[jsaul]

facilty meaning HOPD or ASC?

I would revisit this with insurers, prepare spreadsheet of your proposed bundled fee in office vs total cost at ASC or HOPD to them.
We have fortunately been able to get significant fee increases with all our private insurers this way. As a bench mark we started at about 75% of the combined facility + professional fee[/QUOTE

which facility rate are you using? HOPD or ASC? becasue they are different

 

[Ducttape]

I found ASC rates by asking an employee there (discretely of course)

and you trust this person why?

 

[lonelobo]

and you trust this person why?

Because I saw the EOB's

 

[Jcm800]

No. The pendulum does need to swing in the direction it is going but the guillotine of revolution beheads both the innocent and the guilty equally without deference to standards of care or in this case, rule of law.

do you have any specifics you could share?

 

[Papa Lou]

Good morning fellow SDNer's:

I have been researching and planning on starting a pain practice and need your opinions into the following issues:

1. Location:
   • I'm currently in a non-compete clause with the employer I'm working for. It basically restricts me from working in the area I want to open my primary office in.
   • However, I can drive 15 more minutes out of this area and start the practice over there. The market seems to be good there also.
   • I do eventually want to move into my preferred area though. I'm concerned about having two separate locations though this seems to be the common trend for any solo practice provider regardless of the subspecialty in my area.
   • Question for you guys: If I invest good money to start in this outside area, would it cost me more or less the same amount when I'm ready to open in the area I want to open in eventually. What is typically the expense to add a satellite location?
2. Start PP now vs in 2 years:
   • One option is to work some odd job for 2 years and come back to start a single location PP
   • This sounds financially less risky, but obviously the later you start it the more time I have to wait till the practice is financially rewarding down the road.
   • With all the changes happening in healthcare, it looks like it is getting harder and harder for single guys to succeed. So, I'm concerned that I may loose out if I wait for 2 years in starting a PP
   • Question for you guys: What is your opinion on this? What would you do if this were you right now.
3. Should I even start a PP:
   • With the way healthcare field is currently, I'm a bit nervous about starting a PP
   • Most of the pain clinics in my area were purchased by a single corporate entity. They purchased three clinics in a matter of two years. I'm confused as to why this happened because I feel like this area is a very successful one for individual pain docs.
   • My current job makes me decent money in the low 350-450K range (likely around 400K depending on quarterly bonuses), but the overhead can reach 65-70%. Unless, I buy into ASC shares, there is no chance of making more. They did offer me buy-in for the ASC, but I'm undecided at this point. My reason for branching is not just overhead, but the surgeon who started the practice could be a d**k and I feel like I'm constantly under his radar due to his crazy micromanagement. This may be a good thing for the practice, but it bothers me to no end. I feel like I'm in control of my clinic, but he reminds me he is the boss every instance he gets by doing verbal punches.
     
   • Questions for you guys:
     • Is there a hidden issue that is making these providers to sell their PP to a corporate entity?
     • Is it even worth it to start your own or drink from a common fountain as someone on this forum put it. Should I suck it up and stay in my current job for the rest of my life and just deal with issues at my current practice?
4. Capital needed to start a PP:
   • What kind of capital is needed to start a bare minimum PP with a Fluoro suite. My calculation is around 100k-150K and this also includes salary for a front desk/office manager person and a MA to help with patients as well as help with C-arm during procedures.
   • The large expenses I included are:
     • Office space large enough for fluoro suite: 25K/year
     • Fluoro suite build expenses (?????). Any input as to the cost of this?
     • A comprehensive EMR with EPM and RCM. Four percent of total collections. I'm looking into EclinicalWorks vs CureMD vs Athena in the same order of preference: No upfront cost if I go with CureMD. ECW is $500/month per provi
     • Furniture(Front office, exam rooms, fixed fluoro table, computers, and phones): 15K
     • Two employees: 50K/year between them
     • Initial medical supply orders: 10K
     • My tail coverage and one year malpractice premium: 20K
     • Consultant to get the practice started: 10K
     • Rent Fluoro machine: 5K/year
     • Buy used or new RFA machine: 15K
     • Any big ticket items I'm missing here, please add to this list
5. Doing all of this to build a practice only to make it a satellite office 2 years later and start allover again is concerning even though both locations could be successful. What you guys think?

Lot more to ask, but I'm just taking it slow and steady. I'm sure more questions will popup as time goes on.

Thnx for all your input.....

-ML

two employees is not gonna cut it not even close. 25k each is right. I use eCW for emr; it's decent. Get a consultant that knows PM clinics and has experience or don't bother at all. forget the RFA machine use an ASC for that and do MBB at your place. Rent at 25k a year for a place that's at least 2000 sq feet sounds cheap I don't know how you can find that anywhere but kudos if that's your area pricing. get a cheap table and the equipment is cheap to actually inject (needles drugs syringes). Starting a new practice is hard, hard, hard.

 

[hyperalgesia]

How old do you guys think is too old to start your own pp? For example, if you move to another state and you plan to work another 5 years or so, is it worth it? For me, I think 5 years would not be worth it. 10 in the right environment, yes.

 

[lonelobo]

How old do you guys think is too old to start your own pp? For example, if you move to another state and you plan to work another 5 years or so, is it worth it? For me, I think 5 years would not be worth it. 10 in the right environment, yes.

I agree I think 5 years is pretty small window considering all the trouble starting from scratch, might find a place where a Hospital would guarantee some money if you promise to stay in community until your practice gets up and going