Building a successful solo practice

[newpodgrad]

https://www.thehealthlawpartners.com/files/can_solo_practitioners_and_small_group_practices_survive_in_today.pdf

This is kinda scary too

---

Members don't see this ad.

 

[Feli]

Solo PP is and always will be viable. The better question is if it is the best choice.

In any metro or HCOL area, it is very tough to be solo due to the cost inefficiencies. Rent is high, staffing is high, marketing $ + time is needed, multiple locations are often needed (so even more dead time), commutes are rougher and less predictable. Hospitals and payers are more competitive, patients are fickle due to many choices, etc. It really helps to max office/staff efficiency, get patients in fairly quick, have vaca coverage, spread costs of equip between multiple docs generating $$ from them, etc.

In rural or suburbs, solo is more viable since the costs of space + staff are lower, the hospital may help docs out, there are fewer choices (pts won't get lost to competition when you take vaca, CME, etc). To the contrary, even one or two more good specialists coming into the area can be damaging to existing ones.

My two main offices right now are a smallish ~125k metro and a ~15k small town significantly outside of such. In my metro office, if we shut down or even lost our phones for a couple weeks, we'd probably lose half our patient and refer base to competition. People choose mainly on convenience and quickness of appointments. We would never do that since it's a large group with 2+ docs regularly at each location and ability to cross-cover if needed.
...Now in the small town, I could probably go away 6 weeks of vacation without any backup help and still only lose 10-20% or fewer of the pts or referrals. The other docs know me, I have a rep for doing good work, and mainly, the area residents and workers have few other choices without driving quite a ways. In the metro, they can literally go across the street... or across the other street and into the hospital office building and have a half dozen other DPMs between just those two competitiors - not to mention tons of others around town.

I feel a small/med group is the best choice in any situation... and it is proven in practice mgmt studies. The rare exceptions of truly rural exist where solo (pref as hospital's employee) can be best choice, mainly because the population can barely support one doc of the specialty. As was mentioned, anywhere so small that solo is highly viable is also likely a place where if one major employer or tourist attraction or interstate exit or whatever changes, then your office there is sunk... so you want to let the hospital take that risk.

 

[619]

however, I fear that insurance contracts will continue to become less and less friendly for solo/small group practices under this trend

That's why a solo doc/small group should join an independent physician association whenever possible.

 

[heybrother]

That's why a solo doc/small group should join an independent physician association whenever possible.

Have you done this?

 

[HardRoadPaved]

We are physicians? I thought we are podiatric physicians.

 

[619]

Have you done this?

Yes. Recently joined the IPA at my hospital msg group. Getting reimbursed the same as the hospital employed physicians and the amount is more than doubled for some insurance. An example, Aetna with my IPA reimburses Matrixectomy 11750 at $432. 99204 pays $291. I don't know about y'all but for a new patient ingrown nail procedure, I bill 99204 + 11750. Means I get paid over $700 for that visit that takes me about 15 mins.

 

[Feli]

... I don't know about y'all but for a new patient ingrown nail procedure, I bill 99204 + 11750. Means I get paid over $700 for that visit that takes me about 15 mins...

Yep, PHOs and IPAs and such are generally well worth it for the assist getting onto and staying on payers, better reimburse, etc. It is smart to inquire at every local hospital (sometimes worth getting on staff just for that PHO membership). I have found that the rural hospitals have the best ones, but they are all well worth the price of admission.

I don't really do 99204s ("moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter") unless they have 3+ problems or need a lot of Rx and workup or a ton of time. It is not wrong, esp if the visit + procedure + note takes that much time. As you see higher volume, it gets harder to bill on time, though... even with the new rules with procedures, charting, etc counting toward E&M time. A straightforward ingrown + matrix with nothing else (or just onycho or cellulitis or something) is a just ~30mins for me and 99203 since it was little decision making. Maybe 99204 if they also had tinea + PTTD or two unrelated things I had to think/educate/Rx them on top of the ingrown, then I would do 99204+11750+XRs if I maybe did matrix, Rx antifungal crm, discuss PTTD options and XR, U/S PT tendon, Rx Ariz brace and disp arch supports or something? I dunno, I barely ever do that much in one visit since I'd get too behind (would kick the PTTD tx/edu or the matrix until their f/u to stay on pace). I think my 99202/3/4 and 99212/3/4 go something like 10/70/20% (I only do level 5s if real complicated and pt sent to hospital or some similarly complex hour visit... which is hopefully just a few per year)... I just do a lot of procedures and a lot of DME and in-office imaging.

I am probably on the conservative end since I came out with the old E&M rules (procedure time doesn't count in E&M), but I bet less than half of DPMs do 99204 for a basic NP ingrown visit for matrix. My 99204s are more just 3+ clearly different complaints, revision surgery consult or trauma that takes awhile, DM with complications or wound, etc pts that have more decision making and edu, Rx, tests interpreted, tests ordered, refers, more diverse ICDs in the note, etc. I will fully admit that I often err to the level 4s for pts who are borderline low vs moderate decision making encounters and they brought their own imaging or refuse my office DME or tests (since it still takes my pulling up CD, explaining the DME, explaining the test, etc). Coding is definitely not an exact science

 

[newpodgrad]

How does one join the IPA?

 

[dtrack22]

I don't know about y'all but for a new patient ingrown nail procedure, I bill 99204 + 11750.

It only meets moderate complexity for a minor procedure if the patient has identified risk factors. So you are overcoding on a majority of them most likely.

 

[Feli]

How does one join the IPA?

Through the area hospitals (90+ percent of them).

This is one of the many pitfalls of starting solo out of training: most hospital applications can't be started/completed until you have your residency certificate +/- full state license in some areas. They will then take months to get approved. Many insurance plan apps you apply to yourself or that the PHO/IPA will help with also require board qual/cert (which can't be done until end of residency).

It can be done, but it's infinitely easier to have an employer do it for you... or to register for insurances, hospitals, etc in the place you want to start solo gradually while you have a job and are working with an established office/group/hospital for stable income and exp.

 

[heybrother]

I won't comment on the coding except to say those values exceed my fee schedule.

So there is apparently an IPA in my town with more than 100 physicians/surgeons etc. Their website looks like its from the 1980s. When I looked up IPA and my town the first thing I saw was local breweries. So I spelled it out further - interestingly, while the IPA group was listed Google also pulled up the the Hospital ACO I'm a part of. They don't negotiate for us but they do apparently help us with MIPS. I wonder if we simply haven't been asking the right questions. There's a DPM in my town who is in a IPA from a much bigger city 5 hours away. They only have 20 members though so I'm not sure how much that could help with contracting. This other DPM implied to me it helped with the cost of things like health insurance, supplies, and what not, but I'd rather simply be paid more for my services.

 

[Feli]

... When I looked up IPA and my town the first thing I saw was local breweries...

Even better, especially on a Friday.

 

[Jummy Biffett]

What are the approximate costs of joining an IPA?

 

[dtrack22]

What are the approximate costs of joining an IPA?

Depends, I’ve seen some that are $400-500 per year in dues and some that are $2000-3000

 

[Feli]

What are the approximate costs of joining an IPA?

I have typically seen $250-1000 range to enroll (one time, then they renew free or very low cost since the up-front sign-ups are the main work for them). There are some PHOs and IPAs that are higher or lower in cost. They all do basically the same things.

All are worth it for solo or small group... but usually not as necessary for med/large group, which will almost invariably do credentialing in-house or hire a company like through their billing company/service, through MD cred or similar (ok option for small/solo also).

 

[heybrother]

Reading about them is interesting. It appears in some circumstances there have been anti-trust concerns.

Aetna pays me like pitifully - like $147 for a 11750 and $88 for a 99203. I look at the above and think - everyone should be in some sort of group structure but there has to be a catch or something. Even if the dues were $3K a year I'd pay that back in a week based on the rates above.

 

[619]

Aetna pays me like pitifully - like $147 for a 11750 and $88 for a 99203.

This was very similar to my reimbursement with Aetna before I joined the IPA. I must say that Aetna is an outlier though with my IPA. However overall reimbursement is greatly improved joining an IPA.

 

[heybrother]

My IPA journey continues. I called the ACO I'm in. They don't do any negotiation for non-employees. I then called the in town IPA from the 1980's. No answer. I decided - screw it. I drove to their office. I arrived at a building just off the free-way. It was one of those small buildings where you can rent cheap office space down hallways. Quite the labyrinth. The IPA appears to have a small office. One window. The lights were off and no one answered when I knocked. I can't help but wonder if an organization like this must be some sort of small branch for a larger organization. Perhaps there's some regional small timer who does the credentialing but they reach elsewhere for things that require negotiating.

 

[Feli]

My IPA journey continues. I called the ACO I'm in. They don't do any negotiation for non-employees. I then called the in town IPA from the 1980's. No answer. I decided - screw it. I drove to their office. I arrived at a building just off the free-way. It was one of those small buildings where you can rent cheap office space down hallways. Quite the labyrinth. The IPA appears to have a small office. One window. The lights were off and no one answered when I knocked. I can't help but wonder if an organization like this must be some sort of small branch for a larger organization. Perhaps there's some regional small timer who does the credentialing but they reach elsewhere for things that require negotiating.

Haha... I would just keep calling and try to sign up whenever - even if they can only add a couple payers you don't have now or better rates on even one or two. Most are worthwhile as an adjunct to even your own good credentialing and CAQH work.

Like I said, most of the PHOs and IPAs don't really do much besides some credentialing of new docs they add (hence why they cost to join yet are usually free or much cheaper to renew). They get the group rates on codes almost automatically since they save the payers time; they don't really have to do much on that end. One decent credentialer with a bit of internal or external help can take care of signing up payer/hospital apps for dozens of docs in a MSG or large group, so it is probably just what you said if it's a smaller IPA (one person with mostly remote work and outside help). Even most pretty big IPAs just have a couple staff and a couple docs listed for their guidance and contacts. Your description makes it sound pretty ominous and boiler roomy, though... you'd expect Vin Diesel (or even Neo) to jump out of the dark concrete corners.

 

[heybrother]

Haha... I would just keep calling and try to sign up whenever - even if they can only add a couple payers you don't have now or better rates on even one or two. Most are worthwhile as an adjunct to even your own good credentialing and CAQH work.

Like I said, most of the PHOs and IPAs don't really do much besides some credentialing of new docs they add (hence why they cost to join yet are usually free or much cheaper to renew). They get the group rates on codes almost automatically since they save the payers time; they don't really have to do much on that end. One decent credentialer with a bit of internal or external help can take care of signing up payer/hospital apps for dozens of docs in a MSG or large group, so it is probably just what you said if it's a smaller IPA (one person with mostly remote work and outside help). Even most pretty big IPAs just have a couple staff and a couple docs listed for their guidance and contacts. Your description makes it sound pretty ominous and boiler roomy, though... you'd expect Vin Diesel (or even Neo) to jump out of the dark concrete corners.

It was slightly cleaner than the above but I did keep looking over my shoulder. Perfect world the locals would get back to me because otherwise I'm going to have to try groups in cities hours away. I looked at the websites for 2 large IPA that both contained large numbers of podiatrists. Both were trivially affordable though I'd pay thousands for a 20% increase. One of them I read all their application paperwork and saw nothing that would make me lose hope. Interestingly, one of them had a password protected section of their website literally entitled "fee schedules". Like you said though - pretty certain I'd accept someone else's schedule without looking because there's no world where MDs are accepting what I'm currently getting. I was pleased to see essentially every plan but 1 that I accept on their list. This is an interesting process.

So for anyone who hasn't done this before.
-IPAs do seem to have websites
-They often list their board / officers etc
-There's apparently historic issues with anti-trust issues because technically IPAs represent individual practices that are competing but if competitors join together to then target an insurance company ie. none of the members will accept the payors offer then that could represent anti-trust type behavior. I'm not a lawyer. This is a cursory explanation. Essentially you are working together in concert even though you are competitors.
-Apparently they get around the above by using the "Messenger Model"
-They often list insurers that they have "Master Agreements" with
-They essentially become your attorney at fact or something like that for representation/discussion with managed care, insurance etc
-There original purpose was related to negotiating with managed care / capitated contracts etc ie. managing and taking on risk
-However, a lot of that has apparently gone away since capitation is way less common though Medicare wants the future to be value based contracts instead of fee for service
-IPAs sometimes provide list of their members (which is helpful if you wonder will they accept a podiatrist)
-There often is some sort of review/qualification process based on something called like NCQA or something like that
-The paperwork though essentially resembles the kind of tedious horrible stuff you get from CAQH where you have to list your entire life and spell out everything including how you handle admissions ie. what hospitalist will accept from you

 

[dtrack22]

Your description makes it sound pretty ominous and boiler roomy, though... you'd expect Vin Diesel (or even Neo) to jump out of the dark concrete corners.

But we’re talking about Podiatry so you’re more likely to get Old Gregg…

 

[heybrother]

But we’re talking about Podiatry so you’re more likely to get Old Gregg…

View attachment 353867

There were some very sketchy looking cosmetology offices in this building so if the above had walked out I wouldn't have been surprised. Also, I have never seen The Mighty Boosh. Should I have?

 

[heybrother]

I'm just going to keep bumping my own story here. Still no word from the local IPA. I called an out of town IPA that's the closest IPA. They are open to podiatrists. They have 1000+ members. They are not bothered I'm in a different town. They are going to send me an NDA and a form to submit codes and they'll send me sample fee schedules to compare to my direct contracting. Very fun. Thanks to all the people above talking about this. I remain convinced that the number one thing holding my practice down is poor contracted rates.

Edit: Sadly they do not contract with Aetna in my area. They don't contract with Humana either but I don't care.

 

[dtrack22]

They don't contract with Humana either but I don't care

Nobody should contract with Humana

 

[newpodgrad]

Spoke to a credentialling company.

Said they would be able to contract contract with insurances.

20 payor contracts would be about 5k. Seems reasonable but idk.

Was told that average wait time for private insurers is about 7 months.

Medicare would take about 45 days, and I’d be able to see patients right away after application is submitted.

Also starting new practice with new tax ID/NPI could take longer. Whereas buying a practice would be quickest, however, the doc selling would need to be part of a group contract. If they’re solo there’s a chance the insurance contracts are tied to the individuals NPI.

Also, my fear is closed insurance panals…not sure how to go about those…I was told my location that I’m scooping out is ok at the moment but can change without notice.

Any solo docs on here that can help verify and guide?

 

[icebreaker32]

If insurance panels are closed you can appeal and very well might get added if you have a compelling reason......such as working in a rural area and treating an underserved population or one of very few in area that treat diabetic wounds etc

Some insurance panels are closed even in areas there is a need and make you play this game.