Conflicting advice about starting own practice

[BW15]

Hi everyone,

I'm currently a pain fellow and my goal has always been to start my own practice. I've been reading about starting my own practice for years and have read every thread I could find and it seems like there is a lot of conflicting advice out there.

Some recommend to work for someone else for 1-2 years out of fellowship to gain experience before trying to start your own practice.
Vs.
Others say that you won't gain the proper business management experience working for someone else and the best way to do it is to jump right into it after fellowship.

My plan was to do part time anesthesia while subleasing office space and building my pain practice on the side. It sounds good in theory, but I just have a lot of doubt about it since everyone always stresses how hard it is to start your own practice and I'll be moving to the suburbs of a large city with HCOL. I'm currently looking to see what type of jobs are out there, but most of them look like predatory jobs with no partnership.

I have some money I had saved for a down payment on a house, but I'm going to hold off on that for a few years, so I'll have some of that just as an emergency fund if I need it. But I'm also concerned that I'll use all that money and if the practice fails then I'm stuck with nothing.

I wanted to see what this forums current recommendations would be.

Thanks

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[drusso]

Hi everyone,

I'm currently a pain fellow and my goal has always been to start my own practice. I've been reading about starting my own practice for years and have read every thread I could find and it seems like there is a lot of conflicting advice out there.

Some recommend to work for someone else for 1-2 years out of fellowship to gain experience before trying to start your own practice.
Vs.
Others say that you won't gain the proper business management experience working for someone else and the best way to do it is to jump right into it after fellowship.

My plan was to do part time anesthesia while subleasing office space and building my pain practice on the side. It sounds good in theory, but I just have a lot of doubt about it since everyone always stresses how hard it is to start your own practice and I'll be moving to the suburbs of a large city with HCOL. I'm currently looking to see what type of jobs are out there, but most of them look like predatory jobs with no partnership.

I have some money I had saved for a down payment on a house, but I'm going to hold off on that for a few years, so I'll have some of that just as an emergency fund if I need it. But I'm also concerned that I'll use all that money and if the practice fails then I'm stuck with nothing.

I wanted to see what this forums current recommendations would be.

Thanks

Go as low overhead as you can in the beginning: Lease or sub-lease space. Do your procedures at an ASC. Consider using the "visiting physician space" at a nearby hospital for a per diem rate with staff included. Use a subscription-based EHR with built-in billing capability (Athena for example). Yes, the EHR/billing company is expensive, yes you could do it cheaper other ways, but think of the first two years as a "proof of concept." Use those years to build your referral network--speaking of which plan on relentlessly marketing yourself. Go to Rotary meetings, Chamber of Commerce, Toastmasters, senior centers, etc. You've got to put yourself in front of people constantly. Once you're established you can start looking for efficiencies.

I have a checklist of essential thing you need to need to do to start a practice. PM me and I'll send it to you. There is no greater satisfaction than owning your time and your destiny. If you muster the courage to do it, remain disciplined, take care of patients, then you won't fail.

 

[pmrmd]

I would advise if you have cash use it to get the essentials that make your practice thrive. A C-arm in house let’s you treat patients quickly and efficiently and they DO notice and appreciate it. You would love to see a doctor and get treated on your visit instead of having to fork over a facility fee at some ASC. The economics of PP don’t work without your own equipment. Buy it, depreciate it, use it. Make sure someone is there to answer the phone when you are doing your gas job. Patients love a real person on the other end of the phone line. The startup costs are more than you anticipate by a factor of 3 or 4.

 

[strike5858]

Go for it, I jumped right in out of fellowship last year and I haven’t looked back. Sublease your space. Start with one employee. Live like a fellow. The moonlighting money will get you through. Would consider taking out a loan though. Depending on your state you will have a hefty malpractice premium you need to pay upfront. I waited to buy my equipment. Did my procedures At the hospital. This helped me generate referrals easier. 1 year in and I’m getting about 60-70 new referrals a month. I could do better with my marketing. I will be working on that hard this year and also just purchased my equipment for in office procedures.

 

[SSdoc33]

this question is location-specific. suburbs with high COL often have saturated pain markets, or poor payer contracts. i know of several local PP pain groups that have failed near me.

if you were to open up a practice in nebraska, sure, go for it. in suburban chicago or NY? thats a lot tougher

 

[deleted993114]

Hi everyone,

I'm currently a pain fellow and my goal has always been to start my own practice. I've been reading about starting my own practice for years and have read every thread I could find and it seems like there is a lot of conflicting advice out there.

Some recommend to work for someone else for 1-2 years out of fellowship to gain experience before trying to start your own practice.
Vs.
Others say that you won't gain the proper business management experience working for someone else and the best way to do it is to jump right into it after fellowship.

My plan was to do part time anesthesia while subleasing office space and building my pain practice on the side. It sounds good in theory, but I just have a lot of doubt about it since everyone always stresses how hard it is to start your own practice and I'll be moving to the suburbs of a large city with HCOL. I'm currently looking to see what type of jobs are out there, but most of them look like predatory jobs with no partnership.

I have some money I had saved for a down payment on a house, but I'm going to hold off on that for a few years, so I'll have some of that just as an emergency fund if I need it. But I'm also concerned that I'll use all that money and if the practice fails then I'm stuck with nothing.

I wanted to see what this forums current recommendations would be.

Thanks

I ran a very busy practice for a number of years. I left that about two years ago and it was taken over by a new grad, who is losing about $2K per day.

1. Keep your overhead as low as possible
2. Low overhead- but don't skimp on staff. Your low overhead is not worth much if you can't be efficient. Unanswered phones is a good way to kill a practice.
3. Try to link up with a neurosurgery/spine group. Both groups are synergistic with pain management and can be a good source of direct procedure patients. Internal med/primary care will have a large degree of garbage
4. If doing med management, look at it like a "loss leader" and employ NPs to see those patients. Med management is a losing proposition for a physician only pain practice.
5. Get some idea of the wait times for pain practices in your area. If people can get in that week, chances are it is saturated.
6. Choose a location outside of a major met area- less competition.
7. Check into the insurance demographics of your area- a high medicare/Medicaid population will kill you, regardless of how busy you are.
8. Doing procedures in an office is far more efficient. However, you have the cost of a c-arm and table. It really comes down to how fast you are at procedures.
9. Actually go out and visit the potential referring practices before you set up and leave them an info brochure and contact information. VERY FEW docs actually go physically out to practices and talk to them. Make sure you give the brochure to THIER SCHEDULERS and leave them treats. The schedulers make the referrals.
10. Send out an interesting article on pain medicine that is relevant to them about every 2-3 months. No one else does that and it will be appreciated and keep your name at the top of their list.
11. Be careful about employees- don't hire youngsters as they don't work as hard and tend to get pregnant


Running your own practice is a lot more work, but in general, higher reimbursement if done right. I am at the end of my career and looking to move to an employed position, as I am simply worn out by the business aspect of practice, which I never liked in the first place.

 

[drusso]

I ran a very busy practice for a number of years. I left that about two years ago and it was taken over by a new grad, who is losing about $2K per day.

1. Keep your overhead as low as possible
2. Low overhead- but don't skimp on staff. Your low overhead is not worth much if you can't be efficient. Unanswered phones is a good way to kill a practice.
3. Try to link up with a neurosurgery/spine group. Both groups are synergistic with pain management and can be a good source of direct procedure patients. Internal med/primary care will have a large degree of garbage
4. If doing med management, look at it like a "loss leader" and employ NPs to see those patients. Med management is a losing proposition for a physician only pain practice.
5. Get some idea of the wait times for pain practices in your area. If people can get in that week, chances are it is saturated.
6. Choose a location outside of a major met area- less competition.
7. Check into the insurance demographics of your area- a high medicare/Medicaid population will kill you, regardless of how busy you are.
8. Doing procedures in an office is far more efficient. However, you have the cost of a c-arm and table. It really comes down to how fast you are at procedures.
9. Actually go out and visit the potential referring practices before you set up and leave them an info brochure and contact information. VERY FEW docs actually go physically out to practices and talk to them. Make sure you give the brochure to THIER SCHEDULERS and leave them treats. The schedulers make the referrals.
10. Send out an interesting article on pain medicine that is relevant to them about every 2-3 months. No one else does that and it will be appreciated and keep your name at the top of their list.
11. Be careful about employees- don't hire youngsters as they don't work as hard and tend to get pregnant


Running your own practice is a lot more work, but in general, higher reimbursement if done right. I am at the end of my career and looking to move to an employed position, as I am simply worn out by the business aspect of practice, which I never liked in the first place.

This is pure gold. You should tattoo it on the inside of your right forearm and read it Q 15 minutes...

 

[hyperalgesia]

The main things you want to have signed, sealed and delivered, before you make any major, long term financial commitments are:
1. Referral sources or marketing is PROVEN, yielding a steady flow of quality patients.
2. You are on a sufficient number of insurance panels in your area.

Until the above elements are satisfied, avoid the temptation and stay light on your feet. Use one 1099 scheduler/MA., sublet office space, use ASC for procedures, use paper charts or other cheap EMR.

 

[Ducttape]

Regardless of what path you choose - leave quality time with your spouse and quality time to study for boards.

 

[deleted993114]

This is pure gold. You should tattoo it on the inside of your right forearm and read it Q 15 minutes...

That is pretty funny- okay, so I am a blowhard. Having been married 30 years, I can take a good slap on the back of the head when I get a little out of control. I did appreciate the humor.

However, I do actually believe those things and have found them to be true over time. Of course, many others have provided the guy with a lot of very useful information that will be helpful, such that he does not have to "reinvent the wheel" and make rookie mistakes that are costly.

 

[cowboydoc]

This is pure gold. You should tattoo it on the inside of your right forearm and read it Q 15 minutes...

Don't listen to Dr. Usso's advice regarding tattoos. I've regretted the purple butterfly fibro awareness tattoo from day #1. Hawkeye is spot on, but you'll have to clean up some of the language from a HR perspective. (Hire an experienced person with flexibility and commitment, not an inexperienced "flaky millennial that will get knocked up."

 

[BW15]

Thanks for the advice everyone, I really appreciate it.

I had a few follow up questions:
1. When can I start applying for insurance company panels since I'm not board certified in anesthesiology or pain management yet. Can I sign up for these using a PO Box? Should I pay someone to do this for me or do it myself?

2. Is it worth signing up for medicaid as well seeing how poorly they reimburse?

3. I want to learn the billing/coding aspect of business management. I'll be going to some courses at some conferences. How likely is it someone will be able to do their own billing, especially at the beginning when things are slow? Any other recommendations on how to learn billing/coding?

4. After doing some research it seems like a lot of people prefer Athena for their EMR. Any other recommendations?

 

[deleted185747]

My goal was also to own my own practice and the reason I went into pain. The first 4 years I worked for another guy then for the next two I worked for a different practice. I learned more about longitudinal pain care seeing the same patients over the years. I god better and faster. I learned that brand name drugs require preauths to be filled out and are time consuming. I learned how to handle peer to peers. I learned how to deal with reps. I learned what’s possible and pitfalls.

Then I started my own. I had my own gig for just over a year when I was offered a VA job. All of these paid about the same; $300,000. Owning and operating my own practice was a lot of work and I was busy and stressed; I bought all my own equipment. That means weekly phantom checks of the fluoroscope, maintaining inventory of meds needles and sterilization equipment, making sure sterilizer is tested for spores, California employment laws are followed. The stress of what to do if my one employee didn’t come in to work. She was a perfect employee but the stress of not having a contingency plan was huge. Lots of work after hours doing stupid stuff for the office. Not many people will come on here and tell you they failed at PP. Well the VA offered my the same money for zero stress so I took it! My area is saturated and lots of patients on opioids as well with Medicaid and Medicare. Private insurers match Medicare and also like to deny things.

I’m happy at the VA and doing IMEs on the side 🙂

 

[drusso]

My goal was also to own my own practice and the reason I went into pain. The first 4 years I worked for another guy then for the next two I worked for a different practice. I learned more about longitudinal pain care seeing the same patients over the years. I god better and faster. I learned that brand name drugs require preauths to be filled out and are time consuming. I learned how to handle peer to peers. I learned how to deal with reps. I learned what’s possible and pitfalls.

Then I started my own. I had my own gig for just over a year when I was offered a VA job. All of these paid about the same; $300,000. Owning and operating my own practice was a lot of work and I was busy and stressed; I bought all my own equipment. That means weekly phantom checks of the fluoroscope, maintaining inventory of meds needles and sterilization equipment, making sure sterilizer is tested for spores, California employment laws are followed. The stress of what to do if my one employee didn’t come in to work. She was a perfect employee but the stress of not having a contingency plan was huge. Lots of work after hours doing stupid stuff for the office. Not many people will come on here and tell you they failed at PP. Well the VA offered my the same money for zero stress so I took it! My area is saturated and lots of patients on opioids as well with Medicaid and Medicare. Private insurers match Medicare and also like to deny things.

I’m happy at the VA and doing IMEs on the side 🙂

This is an honest and brave disclosure. The business, admin, regulatory, human resources, and "rainmaking" sides of private practice consume huge amounts of time. It's a whole lifestyle unto itself. Helps if you have a supportive spouse who understands the entrepreneurial mindset. Still, for people with the right temperament and discipline owning your own practice can be rewarding.

 

[deleted993114]

My goal was also to own my own practice and the reason I went into pain. The first 4 years I worked for another guy then for the next two I worked for a different practice. I learned more about longitudinal pain care seeing the same patients over the years. I god better and faster. I learned that brand name drugs require preauths to be filled out and are time consuming. I learned how to handle peer to peers. I learned how to deal with reps. I learned what’s possible and pitfalls.

Then I started my own. I had my own gig for just over a year when I was offered a VA job. All of these paid about the same; $300,000. Owning and operating my own practice was a lot of work and I was busy and stressed; I bought all my own equipment. That means weekly phantom checks of the fluoroscope, maintaining inventory of meds needles and sterilization equipment, making sure sterilizer is tested for spores, California employment laws are followed. The stress of what to do if my one employee didn’t come in to work. She was a perfect employee but the stress of not having a contingency plan was huge. Lots of work after hours doing stupid stuff for the office. Not many people will come on here and tell you they failed at PP. Well the VA offered my the same money for zero stress so I took it! My area is saturated and lots of patients on opioids as well with Medicaid and Medicare. Private insurers match Medicare and also like to deny things.

I’m happy at the VA and doing IMEs on the side 🙂

I think the VA is a good gig, as it is easy, low stress, and you don't need pre-auth for anything. Also, after working five years, you get Blue Cross Federal for life. It's a great place to do clinical research as well. The IMEs are a good gig as well- I have done them for about twenty years and kind of like them, as I get to learn quite a bit about how other people practice.

I am a persona non gratia in the VA system, as the CEO of my former practice (he hated me, as I ratted out two of our docs to the board of medical examiners and they lost their licenses. There was a fairly high profile case that achieved national news over a pain guy that was knocking people off as well) told the local VA that I was losing my medical license and going to jail!!!! I think I am on a "do not hire" list or something. It is hilarious, but I could not get a VA job anywhere in the US. Private practice- no problem- not the VA however.

 

[deleted993114]

Thanks for the advice everyone, I really appreciate it.

I had a few follow up questions:
1. When can I start applying for insurance company panels since I'm not board certified in anesthesiology or pain management yet. Can I sign up for these using a PO Box? Should I pay someone to do this for me or do it myself?

2. Is it worth signing up for medicaid as well seeing how poorly they reimburse?

3. I want to learn the billing/coding aspect of business management. I'll be going to some courses at some conferences. How likely is it someone will be able to do their own billing, especially at the beginning when things are slow? Any other recommendations on how to learn billing/coding?

4. After doing some research it seems like a lot of people prefer Athena for their EMR. Any other recommendations?

1. It will be tough to get on some insurances without board certification. Why aren't you boarded? It is becoming a minimum requirement and is essential not only from a knowledge standpoint, but also PR to referring docs and medico-legal issues. I think in today's climate it would be very tough to be a non boarded pain guy.

2. Learning coding is great, but never do it yourself. If you are not geared up enough, hire an outside pain billing company to do your billing. They will be better than you and it is far less hassle.

3. Medicaid blows everywhere. Some docs will not refer to practices if they refuse medicare or Medicaid. Others don't care. We always capped our Medicaid load at 2%. Nothing can kill a practice more than Medicaid. Not only is the reimbursement bad, but the patients are generally terrible and more work.

 

[deleted993114]

Don't listen to Dr. Usso's advice regarding tattoos. I've regretted the purple butterfly fibro awareness tattoo from day #1. Hawkeye is spot on, but you'll have to clean up some of the language from a HR perspective. (Hire an experienced person with flexibility and commitment, not an inexperienced "flaky millennial that will get knocked up."

Yes- I am a "PC don't". My wife has an MBA with emphasis on HR, so she corrects me quite often. I don't drink, smoke, or curse, so I am a pretty straight arrow and really make a point of not saying anything offensive at work. You need your nurses to be very comfy and view you like they would their dad or grandpa.

However, the age issue is quite true. The only trouble I have ever had with nurses has been youngsters who were either lazy, absent, or had too many days off due to kid illnesses. I really like kids, but I need the nurses to be there and working. Hire gals over 40 and you will be better off. Of course, stating as such is age discrimination- just don't say it publically. I have had a few younger nurses who were very good, but all the bad ones were youngsters.

 

[SSdoc33]

I’m happy at the VA and doing IMEs on the side 🙂

and chart reviews for big brother...... 😡

 

[hyperalgesia]

I’m happy at the VA and doing IMEs on the side 🙂

Lately I've been getting requests to do IME's. It seems like such a horrible gig to me. I picture desperate patients financial status hanging on my every word. How do people get used to this?

 

[drusso]

Lately I've been getting requests to do IME's. It seems like such a horrible gig to me. I picture desperate patients financial status hanging on my every word. How do people get used to this?

 

[KHE]

I'm an optometrist so I can't speak to the specifics of pain practice per se but in general.....

My experience was that "learning business" is not hard. Payroll, taxes, overhead management etc. etc. Millions of people do that.

In health care, the lunacy is in the insurance billing. And you can't really "learn" it while you're in training because what works for Blue Cross of California may fail miserable for Blue Cross of Illinois. You have to learn what "works" for the plans in the area you want to practice in. There's a lot of mistakes made early on and it really impacts your cash flow. As such, I would try to make those early mistakes on someone else's dime.

I would work for someone else for some time once you complete your training but I would do it for as short a time as possible, if that's an option. Many lenders also want to see a couple of years of practice experience before making loans to young doctors, particularly for cold start ups.

 

[hyperalgesia]

Thanks for the advice everyone, I really appreciate it.

I had a few follow up questions:
1. When can I start applying for insurance company panels since I'm not board certified in anesthesiology or pain management yet. Can I sign up for these using a PO Box? Should I pay someone to do this for me or do it myself?

2. Is it worth signing up for medicaid as well seeing how poorly they reimburse?

3. I want to learn the billing/coding aspect of business management. I'll be going to some courses at some conferences. How likely is it someone will be able to do their own billing, especially at the beginning when things are slow? Any other recommendations on how to learn billing/coding?

4. After doing some research it seems like a lot of people prefer Athena for their EMR. Any other recommendations?

1. You should be eligible to get on the panels anywhere if you are board eligible in anesthesia. It really is just dependent on the area. If it's highly competitive, insurance will cap their panels and may enact stricter criteria. But, being board eligible coming out of training is essentially equivalent to being BC.

You will need a SERVICE address first and I don't think it can be a PO box. You can use a hospital where you are credentialed. Then you can get enrolled with Medicare and other insurances. It's not that hard to do it yourself once you get everything organized. You will need all the info and papers for many things in the next few years so have everything as electronic pdfs that can be emailed or faxed quickly.

2. In retrospect, I say yes. Remember one of the most important limiting factors in starting a successful practice is patient referrals. You can always stop taking Medicaid but you can not always recover referral patterns. Referring docs in your area might accept Medicaid and won't appreciate you cherry picking from their pts.

3, 4. I would start with a simple EMR that allows you to submit claims. As you get busy, you can train someone to help you.

Same as everything else, your EMR and billing needs will change as you grow. Start with the basics until you get the referral pattern and insurance panels established.

 

[deleted185747]

and chart reviews for big brother...... 😡

Ha! I haven’t done a UR in about 6 months and don’t miss it one bit lol

 

[SSdoc33]

Ha! I haven’t done a UR in about 6 months and don’t miss it one bit lol

so my guilt trips work!!!!! my wife says they never do.....

 

[Greywater653]

Go as low overhead as you can in the beginning: Lease or sub-lease space. Do your procedures at an ASC. Consider using the "visiting physician space" at a nearby hospital for a per diem rate with staff included. Use a subscription-based EHR with built-in billing capability (Athena for example). Yes, the EHR/billing company is expensive, yes you could do it cheaper other ways, but think of the first two years as a "proof of concept." Use those years to build your referral network--speaking of which plan on relentlessly marketing yourself. Go to Rotary meetings, Chamber of Commerce, Toastmasters, senior centers, etc. You've got to put yourself in front of people constantly. Once you're established you can start looking for efficiencies.

I have a checklist of essential thing you need to need to do to start a practice. PM me and I'll send it to you. There is no greater satisfaction than owning your time and your destiny. If you muster the courage to do it, remain disciplined, take care of patients, then you won't fail.

To OP - I am one year out of fellowship, and have done this almost to a T. Everything in this thread is great advice from what I can tell so far. I'll just add one thought I haven't heard mentioned yet.

The part-time gas/part time practice start-up has worked, BUT... it IS slower (or perhaps it just seems slow to me). I found a great part-time anesthesia, 3 day/week W-2 job w/ full benefits, that left me 2 days a week to work on the practice. I'm fully funding the start-up with my anesthesia salary. At one year out of fellowship, I'm just now starting to see referrals trickle in. This is largely because I've only been beating the path in my community for the last 2-3 months. Leasehold improvements, 6 month payer credentialing time, finding a good employee, starting a website and marketing design, city licensing, blah blah... when you're only in your office 2 out of 5 business days a week because you're in the OR the other 3, it can be slow.

The only obvious mistake I think I've made so far: thinking early on that I could "keep my overhead low" by hiring one MA to be there with me in the office 2 days a week to help see patients, while the other 3 days I would VOiP answer my office calls from the OR or between cases. I found that to just not be tenable, and in hindsight was not very well thought out. Bite the bullet, pay someone good the $16-18/hr full time (or whatever the going rate is in your area) to answer the phones and be your "everything person" for 5 days/week.

Also, I use Athena- it's no panacea, but it is good. We'll see how it holds up when I get busier.

PM me if you want to know anymore of what my experience has been like.

 

[BW15]

My goal was also to own my own practice and the reason I went into pain. The first 4 years I worked for another guy then for the next two I worked for a different practice. I learned more about longitudinal pain care seeing the same patients over the years. I god better and faster. I learned that brand name drugs require preauths to be filled out and are time consuming. I learned how to handle peer to peers. I learned how to deal with reps. I learned what’s possible and pitfalls.

Then I started my own. I had my own gig for just over a year when I was offered a VA job. All of these paid about the same; $300,000. Owning and operating my own practice was a lot of work and I was busy and stressed; I bought all my own equipment. That means weekly phantom checks of the fluoroscope, maintaining inventory of meds needles and sterilization equipment, making sure sterilizer is tested for spores, California employment laws are followed. The stress of what to do if my one employee didn’t come in to work. She was a perfect employee but the stress of not having a contingency plan was huge. Lots of work after hours doing stupid stuff for the office. Not many people will come on here and tell you they failed at PP. Well the VA offered my the same money for zero stress so I took it! My area is saturated and lots of patients on opioids as well with Medicaid and Medicare. Private insurers match Medicare and also like to deny things.

I’m happy at the VA and doing IMEs on the side 🙂

Thanks for the input, I appreciate it.

You mention that all the jobs paid about 300k/year, but you were only 1 year out from starting your own practice. Do you feel like you would have grown to 500k+ if you had just continued?

Also, why do you consider it a failure at PP? It seems to me that you just found a job that was more your style (less administrative/business stress and more patient care and free time).

 

[BW15]

1. It will be tough to get on some insurances without board certification. Why aren't you boarded? It is becoming a minimum requirement and is essential not only from a knowledge standpoint, but also PR to referring docs and medico-legal issues. I think in today's climate it would be very tough to be a non boarded pain guy.

2. Learning coding is great, but never do it yourself. If you are not geared up enough, hire an outside pain billing company to do your billing. They will be better than you and it is far less hassle.

3. Medicaid blows everywhere. Some docs will not refer to practices if they refuse medicare or Medicaid. Others don't care. We always capped our Medicaid load at 2%. Nothing can kill a practice more than Medicaid. Not only is the reimbursement bad, but the patients are generally terrible and more work.

I'm board eligible, but still going through the exams. Everyone keeps mentioning that I shouldn't try to do the billing myself. But I also read that once you know how to do the billing, you'll be very efficient at collecting everything and won't miss things that billing companies will usually overlook.

Medicaid patients are typically very difficult. Logistically I was thinking that I'd rather do extra shifts in the OR and make more money that way than see medicaid patients and get paid peanuts for it.

 

[BW15]

Thanks everyone for the input, I appreciate it. I'm going to keep chugging away.

drusso I tried to send you a PM (start conversation) for the checklist you mentioned, but not sure if i did it correctly. If you see this, please let me know if you received my PM.

 

[drusso]

Thanks everyone for the input, I appreciate it. I'm going to keep chugging away.

drusso I tried to send you a PM (start conversation) for the checklist you mentioned, but not sure if i did it correctly. If you see this, please let me know if you received my PM.

I'm digging around for it.

 

[strike5858]

I'm board eligible, but still going through the exams. Everyone keeps mentioning that I shouldn't try to do the billing myself. But I also read that once you know how to do the billing, you'll be very efficient at collecting everything and won't miss things that billing companies will usually overlook.

Medicaid patients are typically very difficult. Logistically I was thinking that I'd rather do extra shifts in the OR and make more money that way than see medicaid patients and get paid peanuts for it.

Since we are on the topic. I have outsourced my billing at 6% of net collections. How do I go about auditing my billing company to make sure they are collecting as much as possible. We really didn’t pick up until about February of this year but now we have a steady steam of volume. I wanna make sure the company knows I’m gonna hold them Accountable with the billing and collections

 

[deleted993114]

Lately I've been getting requests to do IME's. It seems like such a horrible gig to me. I picture desperate patients financial status hanging on my every word. How do people get used to this?

You are being hired to be a patient advocate. The guidelines can be used legitimately to optimize ratings for the patient while remaining objective.

Most of the IMEs I have seen from other providers are "hired guns" by the employer who give the patient terrible ratings. I generally calculate their true, legit impairment rating, then make sure that the average of the employer and patient ratings arrive at the true impairment number.

When done properly, it is fair to everyone.

 

[cowboydoc]

Most of the IME work I do is being a referee, giving some numbers so they can settle the matter. I occasionally call a card a card when things don't add up, sometimes identify a diagnosis/treatment that was missed, sometimes advocate for a patient getting hosed.

 

[deleted185747]

Thanks for the input, I appreciate it.

You mention that all the jobs paid about 300k/year, but you were only 1 year out from starting your own practice. Do you feel like you would have grown to 500k+ if you had just continued?

Also, why do you consider it a failure at PP? It seems to me that you just found a job that was more your style (less administrative/business stress and more patient care and free time).

Hahaha
1. my plan was to do things the right way and be ethical. My competition allows opioids plus benzodiazepines plus thc. It’s a money/patient grab. I didn’t want to go the opioid route to make money.
2. I wanted to do regenerative medicine but people in my area can’t afford it.
3. The majority of patients in my area are Medicaid which pays about $35/visit and I didn’t accept Medicaid.
4. I was very lean. Me and my MA. Subleased a room one day a week from orthopedic surgeon. MA answered phone from her house 4 days a week. Internet phone thru Costco which rings to your cel phone because you can have it forwarded the hours of your choosing as well as voicemail for unanswered calls and after hours. It worked well. I bought a used fluoroscope, table and rf generator. I used my wife’s autoclave at her dental office for rfa probes 🙂 supplies thru Henry schein and medline. The other 4 days I did QMEs and marketed myself. It was profitable from the beginning. There’s a lot of extra things that go into a setup like this. For example I remember being annoyed at taking a bunch of checks to the bank every week. Little checks for $30 and bigger checks for a few hundred. Tons of paper going back and forth with insurance companies for claims. I had a billing company but still had to tell em what I did and then my ma would scan in the checks and explanations and send it to the billing company so they could mark the charge as paid. Insurance is a bizarro nightmare.
Around this time one of my wife’s employees filed a frivolous lawsuit and it was very stressful. Luckily she had employment practices liability insurance so it covered it. This left a bad taste in my mouth because I was worried about a million things with my business and didn’t realize employees were another potential threat.

Basically I learned that running an ethical pain practice will pay the same as the va in my area but with a lot more work and stress.

 

[hyperalgesia]

Hahaha
1. my plan was to do things the right way and be ethical. My competition allows opioids plus benzodiazepines plus thc. It’s a money/patient grab. I didn’t want to go the opioid route to make money.
2. I wanted to do regenerative medicine but people in my area can’t afford it.
3. The majority of patients in my area are Medicaid which pays about $35/visit and I didn’t accept Medicaid.
4. I was very lean. Me and my MA. Subleased a room one day a week from orthopedic surgeon. MA answered phone from her house 4 days a week. Internet phone thru Costco which rings to your cel phone because you can have it forwarded the hours of your choosing as well as voicemail for unanswered calls and after hours. It worked well. I bought a used fluoroscope, table and rf generator. I used my wife’s autoclave at her dental office for rfa probes 🙂 supplies thru Henry schein and medline. The other 4 days I did QMEs and marketed myself. It was profitable from the beginning. There’s a lot of extra things that go into a setup like this. For example I remember being annoyed at taking a bunch of checks to the bank every week. Little checks for $30 and bigger checks for a few hundred. Tons of paper going back and forth with insurance companies for claims. I had a billing company but still had to tell em what I did and then my ma would scan in the checks and explanations and send it to the billing company so they could mark the charge as paid. Insurance is a bizarro nightmare.
Around this time one of my wife’s employees filed a frivolous lawsuit and it was very stressful. Luckily she had employment practices liability insurance so it covered it. This left a bad taste in my mouth because I was worried about a million things with my business and didn’t realize employees were another potential threat.

Basically I learned that running an ethical pain practice will pay the same as the va in my area but with a lot more work and stress.

Very similar approach here. And very similar outcome.

To OPs question, making >300k in pp requires at least one of the following:
Opioids
Area with little or no competition
Cash pay procedures
Legal work
Ancillary, asc, or other related income
Fraud

 

[drusso]

Hahaha
1. my plan was to do things the right way and be ethical. My competition allows opioids plus benzodiazepines plus thc. It’s a money/patient grab. I didn’t want to go the opioid route to make money.
2. I wanted to do regenerative medicine but people in my area can’t afford it.
3. The majority of patients in my area are Medicaid which pays about $35/visit and I didn’t accept Medicaid.
4. I was very lean. Me and my MA. Subleased a room one day a week from orthopedic surgeon. MA answered phone from her house 4 days a week. Internet phone thru Costco which rings to your cel phone because you can have it forwarded the hours of your choosing as well as voicemail for unanswered calls and after hours. It worked well. I bought a used fluoroscope, table and rf generator. I used my wife’s autoclave at her dental office for rfa probes 🙂 supplies thru Henry schein and medline. The other 4 days I did QMEs and marketed myself. It was profitable from the beginning. There’s a lot of extra things that go into a setup like this. For example I remember being annoyed at taking a bunch of checks to the bank every week. Little checks for $30 and bigger checks for a few hundred. Tons of paper going back and forth with insurance companies for claims. I had a billing company but still had to tell em what I did and then my ma would scan in the checks and explanations and send it to the billing company so they could mark the charge as paid. Insurance is a bizarro nightmare.
Around this time one of my wife’s employees filed a frivolous lawsuit and it was very stressful. Luckily she had employment practices liability insurance so it covered it. This left a bad taste in my mouth because I was worried about a million things with my business and didn’t realize employees were another potential threat.

Basically I learned that running an ethical pain practice will pay the same as the va in my area but with a lot more work and stress.

Owning a small business has been the hardest thing I've ever done in my life. The skills required for success are so different than the skills that get you into and through college, medical school, residency, etc. I think this is where our training lets us down. Physicians are not taught about the business side of medicine. It's nearly 20 years since med school graduation and I caught up with some former classmates. I was amazed that 2/3-3/4 were employed. Many tried to have their own business, but couldn't figure it out and juggle all the responsibility. And these are SMART people--matched into competitive specialties/programs, published good articles and research, etc. Nearing mid-career, many were trying for other kinds of "leadership" positions--CMO's, etc/

The longer I practice, the more and more respect I have for the doctors I knew growing up as a kid. They were hammerheads and relentless and fiercely independent, stubborn muthafckers!

 

[deleted993114]

Very similar approach here. And very similar outcome.

To OPs question, making >300k in pp requires at least one of the following:
Opioids
Area with little or no competition
Cash pay procedures
Legal work
Ancillary, asc, or other related income
Fraud

I disagree. I made $1.3 million plus for about an 18 year stretch at my previous practice. I am glad to no longer be there, as it was a lot of work. I am physically unable to do what I did before (a little cancer problem), but am happier at a slower pace.

1. opioids- yes- we used it as a "loss leader" service and broke even after NP salaries. Oddly, I always had 100 mg as my top dose to non-cancer patients long before the CDC guidelines. I know what the literature says, but there are people who are able to function well and would not otherwise be able to work on four 10s of hydrocodone per day.
2. competition- we had lots of it. The competition was not plugged into a spine group and could not work as fast.
3. cash pay- never did any cash pay
4. legal work- I did some, but it made up only a fraction of my income. I did it as a service to the patients.
5. Ancillary income- our group income was only $50K- very small to clinical revenues
6. fraud- I have always kept my practice "between the lines" and was actually the lowest cost medicare provider for pain in the state. I just had a TON of direct referrals from our surgeons for procedures and it was in a good insurance environment with a low medicare/Medicaid load.

Oddly, with that very same practice, a recent grad is losing $2K per day with a salary of $400K from the clinic. As soon as she starts to be responsible for overhead and off the paid guarantee, she will make less than zero after paying the overhead. The difference?
1. you have to be able to work FAST. Most of the recent grads cannot work fast enough
2. you have to have good outcomes. One bad outcome is greater than 50 successes
3. you have to be full service- that includes meds
4. keep in close touch with your referral base so you know what they want, Give them relevant articles q 2 months
5. be willing to work in patients for procedures that day, regardless of how busy you are, if a doc calls
6. Have to have someone always be able to physically answer the phone- voice messaging blows
7. Have to have short wait times- i.e. two weeks or under. Patients in pain won't wait forever.
8. Have to use NPs to be efficient- you still see and work up patients, but use them for follow ups and meds
9. Have to keep tabs on overhead and see where inefficiencies occur
10. Limit or eliminate "satellites" if your home procedure room is not 100% in use. Satellites are only good if it is a town greater than 20,000 and farther than 60 miles away to increase your "footprint" and you have two or more providers.
11. Have VERY pleasant front office people- you would be surprised how many patients are lost by bad people up front or phone calls that are not returned quickly.
12. Have at least one full time nurse dedicated to phones, independent of your front desk (need 2 receptionists)
13. Never break for lunch- allow your nurses to do so, but have them rotated to keep you working
14. Give your staff year end bonuses- $5K plus is a lot of money for people making $35-$40K, so don't be cheap- they will work harder for you and appreciate it. Make sure your staff is paid more than other pain clinics- they all talk.
15. Buy the staff lunch brought in at least once a week- it is a few hundred bucks and is worth its weight in gold
16. Compliment and thank your staff every day- I have read from a psych standpoint that people value that more than extra cash.
17. Do your "clerical work" at the end of the day when the nurses are gone- doing so during the day slows down the works.
18. Clinic administrators are usually bad business people- you know the business of pain management better than they do. I spent more time "undoing" all the "help" I got from admin, which was usually very poor. Don't let them manage you.
19. Be honest with the patients and formulate your plan as though you had their problem. People will know you are on their side and just not in it for a buck. I could have easily made a ton more money if I did all the procedures that patients were sent in for.
20. BE NICE! You would be surprised how many referring docs say the other pain guys were jerks to their patients.
21. Try to be associated with spine surgeons- they will have nearly 100% procedures, as opposed to primary care. Neurologists, podiatrists, and any surgical speciality (with the exception of neurosurgery and ortho spine) are bad referral sources.
22. Never do inpatient pain management- bad stuff and way too inefficient- it takes an act of God to get something done in a hospital.
23. Don't take ER referrals- almost always bad and they want to dump drug seekers on you.

 

[244913]

A lot of the above is really good advice. However, I don't want to hire mid-levels to prescribe a bunch of medications and most of us aren't being fed procedures directly from Spine groups.

In my area the PP's are all the same- Interventionalists needling and 1-2 midlevels keeping everyone on moderate dose Opioids, often with Benzos.

The prescribing climate has changed significantly even in the past two years. I don't want to be responsible when one of my NP's 90 MED+benzo+THC+soma patients gets in a car wreck or ends up in the ICU and the family lawyers up.

You can be "nice" and "fast" and skilled and Bogduk's illegitimate son. In my area if you aren't dishing narcs you're behind unless you get really creative with PCP referrals.

 

[Ferrismonk]

Very similar approach here. And very similar outcome.

To OPs question, making >300k in pp requires at least one of the following:
Opioids
Area with little or no competition
Cash pay procedures
Legal work
Ancillary, asc, or other related income
Fraud

I disagree. I made $1.3 million plus for about an 18 year stretch at my previous practice. I am glad to no longer be there, as it was a lot of work. I am physically unable to do what I did before (a little cancer problem), but am happier at a slower pace.

1. opioids- yes- we used it as a "loss leader" service and broke even after NP salaries. Oddly, I always had 100 mg as my top dose to non-cancer patients long before the CDC guidelines. I know what the literature says, but there are people who are able to function well and would not otherwise be able to work on four 10s of hydrocodone per day.
2. competition- we had lots of it. The competition was not plugged into a spine group and could not work as fast.
3. cash pay- never did any cash pay
4. legal work- I did some, but it made up only a fraction of my income. I did it as a service to the patients.
5. Ancillary income- our group income was only $50K- very small to clinical revenues
6. fraud- I have always kept my practice "between the lines" and was actually the lowest cost medicare provider for pain in the state. I just had a TON of direct referrals from our surgeons for procedures and it was in a good insurance environment with a low medicare/Medicaid load.

Oddly, with that very same practice, a recent grad is losing $2K per day with a salary of $400K from the clinic. As soon as she starts to be responsible for overhead and off the paid guarantee, she will make less than zero after paying the overhead. The difference?
1. you have to be able to work FAST. Most of the recent grads cannot work fast enough
2. you have to have good outcomes. One bad outcome is greater than 50 successes
3. you have to be full service- that includes meds
4. keep in close touch with your referral base so you know what they want, Give them relevant articles q 2 months
5. be willing to work in patients for procedures that day, regardless of how busy you are, if a doc calls
6. Have to have someone always be able to physically answer the phone- voice messaging blows
7. Have to have short wait times- i.e. two weeks or under. Patients in pain won't wait forever.
8. Have to use NPs to be efficient- you still see and work up patients, but use them for follow ups and meds
9. Have to keep tabs on overhead and see where inefficiencies occur
10. Limit or eliminate "satellites" if your home procedure room is not 100% in use. Satellites are only good if it is a town greater than 20,000 and farther than 60 miles away to increase your "footprint" and you have two or more providers.
11. Have VERY pleasant front office people- you would be surprised how many patients are lost by bad people up front or phone calls that are not returned quickly.
12. Have at least one full time nurse dedicated to phones, independent of your front desk (need 2 receptionists)
13. Never break for lunch- allow your nurses to do so, but have them rotated to keep you working
14. Give your staff year end bonuses- $5K plus is a lot of money for people making $35-$40K, so don't be cheap- they will work harder for you and appreciate it. Make sure your staff is paid more than other pain clinics- they all talk.
15. Buy the staff lunch brought in at least once a week- it is a few hundred bucks and is worth its weight in gold
16. Compliment and thank your staff every day- I have read from a psych standpoint that people value that more than extra cash.
17. Do your "clerical work" at the end of the day when the nurses are gone- doing so during the day slows down the works.
18. Clinic administrators are usually bad business people- you know the business of pain management better than they do. I spent more time "undoing" all the "help" I got from admin, which was usually very poor. Don't let them manage you.
19. Be honest with the patients and formulate your plan as though you had their problem. People will know you are on their side and just not in it for a buck. I could have easily made a ton more money if I did all the procedures that patients were sent in for.
20. BE NICE! You would be surprised how many referring docs say the other pain guys were jerks to their patients.
21. Try to be associated with spine surgeons- they will have nearly 100% procedures, as opposed to primary care. Neurologists, podiatrists, and any surgical speciality (with the exception of neurosurgery and ortho spine) are bad referral sources.
22. Never do inpatient pain management- bad stuff and way too inefficient- it takes an act of God to get something done in a hospital.
23. Don't take ER referrals- almost always bad and they want to dump drug seekers on you.

Hawkeye, I largely agree with you and this is great advice, but hyperalgesia said to make more than 300K you need to write opiates. You wrote opiates. His argument stands.

I think you illustrated the exact system most people use to make lots of money in Pain Medicine:
1. Write opiates
2. Use a midlevel for med refills and followups
3. Spend as little time with the patient as possible (work fast) to see more people
4. Build relationships with referring providers who only want you to do procedures
5. Do paperwork after office has closed

Add in good business practices such as good marketing, happy employees, and being nice and you'll be well above the rest.

Also, for what it's worth, with insurances the way they are now doing same day procedures is virtually impossible.

 

[244913]

In my area the Spine groups:

a. Have their own midlevels prescribing + organ grinding in house Pain Parasite doing their "series of 3"
b. Only send you patients if your midlevel (s) take over their Opioids+Xanax+THC edibles

I'm hospital employed, and what I am trying to do is slowly build a referral network with PCP's outside the system who actually value my skills/bedside manner and time I spend with patients- I'm not seeing 45/day- who then send me all of their fresh, un-worked up pain patients.

If I can somehow build a base of these folks, then I can be the gatekeeper and for every good commercial patient I send to a Spine surgeon they send 1-2 injections my way.

I've discovered this is a long and painstaking process because you have to flush out all the PCP's who just want to dump their disasters on your lap.

 

[Ligament]

I disagree. I made $1.3 million plus for about an 18 year stretch at my previous practice. I am glad to no longer be there, as it was a lot of work. I am physically unable to do what I did before (a little cancer problem), but am happier at a slower pace.

1. opioids- yes- we used it as a "loss leader" service and broke even after NP salaries. Oddly, I always had 100 mg as my top dose to non-cancer patients long before the CDC guidelines. I know what the literature says, but there are people who are able to function well and would not otherwise be able to work on four 10s of hydrocodone per day.
2. competition- we had lots of it. The competition was not plugged into a spine group and could not work as fast.
3. cash pay- never did any cash pay
4. legal work- I did some, but it made up only a fraction of my income. I did it as a service to the patients.
5. Ancillary income- our group income was only $50K- very small to clinical revenues
6. fraud- I have always kept my practice "between the lines" and was actually the lowest cost medicare provider for pain in the state. I just had a TON of direct referrals from our surgeons for procedures and it was in a good insurance environment with a low medicare/Medicaid load.

Oddly, with that very same practice, a recent grad is losing $2K per day with a salary of $400K from the clinic. As soon as she starts to be responsible for overhead and off the paid guarantee, she will make less than zero after paying the overhead. The difference?
1. you have to be able to work FAST. Most of the recent grads cannot work fast enough
2. you have to have good outcomes. One bad outcome is greater than 50 successes
3. you have to be full service- that includes meds
4. keep in close touch with your referral base so you know what they want, Give them relevant articles q 2 months
5. be willing to work in patients for procedures that day, regardless of how busy you are, if a doc calls
6. Have to have someone always be able to physically answer the phone- voice messaging blows
7. Have to have short wait times- i.e. two weeks or under. Patients in pain won't wait forever.
8. Have to use NPs to be efficient- you still see and work up patients, but use them for follow ups and meds
9. Have to keep tabs on overhead and see where inefficiencies occur
10. Limit or eliminate "satellites" if your home procedure room is not 100% in use. Satellites are only good if it is a town greater than 20,000 and farther than 60 miles away to increase your "footprint" and you have two or more providers.
11. Have VERY pleasant front office people- you would be surprised how many patients are lost by bad people up front or phone calls that are not returned quickly.
12. Have at least one full time nurse dedicated to phones, independent of your front desk (need 2 receptionists)
13. Never break for lunch- allow your nurses to do so, but have them rotated to keep you working
14. Give your staff year end bonuses- $5K plus is a lot of money for people making $35-$40K, so don't be cheap- they will work harder for you and appreciate it. Make sure your staff is paid more than other pain clinics- they all talk.
15. Buy the staff lunch brought in at least once a week- it is a few hundred bucks and is worth its weight in gold
16. Compliment and thank your staff every day- I have read from a psych standpoint that people value that more than extra cash.
17. Do your "clerical work" at the end of the day when the nurses are gone- doing so during the day slows down the works.
18. Clinic administrators are usually bad business people- you know the business of pain management better than they do. I spent more time "undoing" all the "help" I got from admin, which was usually very poor. Don't let them manage you.
19. Be honest with the patients and formulate your plan as though you had their problem. People will know you are on their side and just not in it for a buck. I could have easily made a ton more money if I did all the procedures that patients were sent in for.
20. BE NICE! You would be surprised how many referring docs say the other pain guys were jerks to their patients.
21. Try to be associated with spine surgeons- they will have nearly 100% procedures, as opposed to primary care. Neurologists, podiatrists, and any surgical speciality (with the exception of neurosurgery and ortho spine) are bad referral sources.
22. Never do inpatient pain management- bad stuff and way too inefficient- it takes an act of God to get something done in a hospital.
23. Don't take ER referrals- almost always bad and they want to dump drug seekers on you.

This is a lot of great advice, and if you want to make a lot of money then yes you need to write meds and have midlevels. It also helps to have a built in referall network of spine surgeons and orthopods; in which case you will be required to write drugs for them in most cases. I presume by "write meds" you mean prescribe opioids, but correct me if I'm wrong. I personally don't think midlevels should exist in specialty care. What we do is too complex. But you do not need to write meds and have midlevels if you want to make less money. I am certainly not a hyper successful private practice physician but have survived for 10 years in solo private practice in a very competitive environment. Spend time with patients, figure out complex pain issues, think outside the box. Less money but more enjoyable practice and life.

 

[Ferrismonk]

In my area the Spine groups:

a. Have their own midlevels prescribing + organ grinding in house Pain Parasite doing their "series of 3"
b. Only send you patients if your midlevel (s) take over their Opioids+Xanax+THC edibles

I'm hospital employed, and what I am trying to do is slowly build a referral network with PCP's outside the system who actually value my skills/bedside manner and time I spend with patients- I'm not seeing 45/day- who then send me all of their fresh, un-worked up pain patients.

If I can somehow build a base of these folks, then I can be the gatekeeper and for every good commercial patient I send to a Spine surgeon they send 1-2 injections my way.

I've discovered this is a long and painstaking process because you have to flush out all the PCP's who just want to dump their disasters on your lap.

c. will send all the medicaid patients to you and keep the commercial in-house

 

[Rocky222Balboa]

Very similar approach here. And very similar outcome.

To OPs question, making >300k in pp requires at least one of the following:
Opioids
Area with little or no competition
Cash pay procedures
Legal work
Ancillary, asc, or other related income
Fraud

This is depressing. You can make 400k as a starting salary doing anesthesia without a fellowship. Why would anyone choose to do pain if the market is truly like this?

 

[Ligament]

c. will send all the medicaid patients to you and keep the commercial in-house

Above all, do not take medicaid patients. 95% are polysubstance abusers and have a lifetime of disability convictions. No show rates through the roof, medlegal risk through the roof, behavioral issues through the roof. They can go to the

This is depressing. You can make 400k as a starting salary doing anesthesia without a fellowship. Why would anyone choose to do pain if the market is truly like this?

You can make more money with much more vacation doing gas. If those are your priorities, you should do gas for sure.

 

[BobBarker]

It just depends on you and your situation. I would tell anyone to bet on himself first, and go for it. Fortune favors the bold.

 

[NJPAIN]

I disagree. I made $1.3 million plus for about an 18 year stretch at my previous practice. I am glad to no longer be there, as it was a lot of work. I am physically unable to do what I did before (a little cancer problem), but am happier at a slower pace.

1. opioids- yes- we used it as a "loss leader" service and broke even after NP salaries. Oddly, I always had 100 mg as my top dose to non-cancer patients long before the CDC guidelines. I know what the literature says, but there are people who are able to function well and would not otherwise be able to work on four 10s of hydrocodone per day.
2. competition- we had lots of it. The competition was not plugged into a spine group and could not work as fast.
3. cash pay- never did any cash pay
4. legal work- I did some, but it made up only a fraction of my income. I did it as a service to the patients.
5. Ancillary income- our group income was only $50K- very small to clinical revenues
6. fraud- I have always kept my practice "between the lines" and was actually the lowest cost medicare provider for pain in the state. I just had a TON of direct referrals from our surgeons for procedures and it was in a good insurance environment with a low medicare/Medicaid load.

Oddly, with that very same practice, a recent grad is losing $2K per day with a salary of $400K from the clinic. As soon as she starts to be responsible for overhead and off the paid guarantee, she will make less than zero after paying the overhead. The difference?
1. you have to be able to work FAST. Most of the recent grads cannot work fast enough
2. you have to have good outcomes. One bad outcome is greater than 50 successes
3. you have to be full service- that includes meds
4. keep in close touch with your referral base so you know what they want, Give them relevant articles q 2 months
5. be willing to work in patients for procedures that day, regardless of how busy you are, if a doc calls
6. Have to have someone always be able to physically answer the phone- voice messaging blows
7. Have to have short wait times- i.e. two weeks or under. Patients in pain won't wait forever.
8. Have to use NPs to be efficient- you still see and work up patients, but use them for follow ups and meds
9. Have to keep tabs on overhead and see where inefficiencies occur
10. Limit or eliminate "satellites" if your home procedure room is not 100% in use. Satellites are only good if it is a town greater than 20,000 and farther than 60 miles away to increase your "footprint" and you have two or more providers.
11. Have VERY pleasant front office people- you would be surprised how many patients are lost by bad people up front or phone calls that are not returned quickly.
12. Have at least one full time nurse dedicated to phones, independent of your front desk (need 2 receptionists)
13. Never break for lunch- allow your nurses to do so, but have them rotated to keep you working
14. Give your staff year end bonuses- $5K plus is a lot of money for people making $35-$40K, so don't be cheap- they will work harder for you and appreciate it. Make sure your staff is paid more than other pain clinics- they all talk.
15. Buy the staff lunch brought in at least once a week- it is a few hundred bucks and is worth its weight in gold
16. Compliment and thank your staff every day- I have read from a psych standpoint that people value that more than extra cash.
17. Do your "clerical work" at the end of the day when the nurses are gone- doing so during the day slows down the works.
18. Clinic administrators are usually bad business people- you know the business of pain management better than they do. I spent more time "undoing" all the "help" I got from admin, which was usually very poor. Don't let them manage you.
19. Be honest with the patients and formulate your plan as though you had their problem. People will know you are on their side and just not in it for a buck. I could have easily made a ton more money if I did all the procedures that patients were sent in for.
20. BE NICE! You would be surprised how many referring docs say the other pain guys were jerks to their patients.
21. Try to be associated with spine surgeons- they will have nearly 100% procedures, as opposed to primary care. Neurologists, podiatrists, and any surgical speciality (with the exception of neurosurgery and ortho spine) are bad referral sources.
22. Never do inpatient pain management- bad stuff and way too inefficient- it takes an act of God to get something done in a hospital.
23. Don't take ER referrals- almost always bad and they want to dump drug seekers on you.

Wow. My hat is off to you Hawkeye2009. I have been in practice probably as long as you have, albeit the first 8 years in academics. I have never come close to those numbers. Much of your advice is very helpful. Some of it applies to a different generation of doctors. Most guys from our era, my self excluded, wanted to work like dogs and make as much money as they could. Those are the guys in anesthesia practice who took as much call as they could, spent little time at home with family, but made $$$. I know lots of guys who went to those practices and are multi-multi-millionaires now and retired or working half time at 50 years of age. Today's docs seem to value quality of life over quantity of cash. They want to eat lunch like a human being and run out of the office at the end of the day rather than spend hours charting. Nothing wrong with that. You should not have to kill yourself to make a decent living in medicine. It may have come to that now but we should have not let it get to that point.

Regarding you comment about the need to be FAST. Do you think that recent grads are not fast because they lack experience or are poorly trained or over concerned with safety? I have witnessed docs do 6 cases per hour who have patients unconscious when then walk in the room and throw a needle in with little concern about where the tip is. Typically everyone gets a series of 3 so eventually at least one needle reaches the target. I have also witnessed 1 or 2 extremely experienced AND extremely talented docs who work with rock star techs and RNs in multiple rooms and can do 10 cases an hour. Their RNs run the RF machine and pull the needles out while the doc has moved on to the next patient in another room. Docs this good with staff this good are RARE. I'm all in favor of efficiency but the assembly line mentality that has permeated medicine is VERY VERY SAD.

With regard to prescribing opioids, most pain docs do it to keep people coming through the door. If you are in an ortho group your ortho partners want this to keep patients happy. Nothing works better to smooth over a bad outcome than a monthly supply of Percocet. It gets the nagging patient out of the surgeons office and that is what they want. The surgeon doesn't care what you do as long as they don't need to deal with the unhappy patient. Unfortunately if you don't prescribe opioids your practice suffers. I loose patients because of this. I just don't see the value in COT for 99.9% of patients. I don't see the maintenance of function, etc that many claim. I can't stomach the BS that goes along with patients on these meds.

 

[drusso]

Regardless of what path you choose - leave quality time with your spouse and quality time to study for boards.

 

[drpainfree]

I disagree. I made $1.3 million plus for about an 18 year stretch at my previous practice. I am glad to no longer be there, as it was a lot of work. I am physically unable to do what I did before (a little cancer problem), but am happier at a slower pace.

1. opioids- yes- we used it as a "loss leader" service and broke even after NP salaries. Oddly, I always had 100 mg as my top dose to non-cancer patients long before the CDC guidelines. I know what the literature says, but there are people who are able to function well and would not otherwise be able to work on four 10s of hydrocodone per day.
2. competition- we had lots of it. The competition was not plugged into a spine group and could not work as fast.
3. cash pay- never did any cash pay
4. legal work- I did some, but it made up only a fraction of my income. I did it as a service to the patients.
5. Ancillary income- our group income was only $50K- very small to clinical revenues
6. fraud- I have always kept my practice "between the lines" and was actually the lowest cost medicare provider for pain in the state. I just had a TON of direct referrals from our surgeons for procedures and it was in a good insurance environment with a low medicare/Medicaid load.

Oddly, with that very same practice, a recent grad is losing $2K per day with a salary of $400K from the clinic. As soon as she starts to be responsible for overhead and off the paid guarantee, she will make less than zero after paying the overhead. The difference?
1. you have to be able to work FAST. Most of the recent grads cannot work fast enough
2. you have to have good outcomes. One bad outcome is greater than 50 successes
3. you have to be full service- that includes meds
4. keep in close touch with your referral base so you know what they want, Give them relevant articles q 2 months
5. be willing to work in patients for procedures that day, regardless of how busy you are, if a doc calls
6. Have to have someone always be able to physically answer the phone- voice messaging blows
7. Have to have short wait times- i.e. two weeks or under. Patients in pain won't wait forever.
8. Have to use NPs to be efficient- you still see and work up patients, but use them for follow ups and meds
9. Have to keep tabs on overhead and see where inefficiencies occur
10. Limit or eliminate "satellites" if your home procedure room is not 100% in use. Satellites are only good if it is a town greater than 20,000 and farther than 60 miles away to increase your "footprint" and you have two or more providers.
11. Have VERY pleasant front office people- you would be surprised how many patients are lost by bad people up front or phone calls that are not returned quickly.
12. Have at least one full time nurse dedicated to phones, independent of your front desk (need 2 receptionists)
13. Never break for lunch- allow your nurses to do so, but have them rotated to keep you working
14. Give your staff year end bonuses- $5K plus is a lot of money for people making $35-$40K, so don't be cheap- they will work harder for you and appreciate it. Make sure your staff is paid more than other pain clinics- they all talk.
15. Buy the staff lunch brought in at least once a week- it is a few hundred bucks and is worth its weight in gold
16. Compliment and thank your staff every day- I have read from a psych standpoint that people value that more than extra cash.
17. Do your "clerical work" at the end of the day when the nurses are gone- doing so during the day slows down the works.
18. Clinic administrators are usually bad business people- you know the business of pain management better than they do. I spent more time "undoing" all the "help" I got from admin, which was usually very poor. Don't let them manage you.
19. Be honest with the patients and formulate your plan as though you had their problem. People will know you are on their side and just not in it for a buck. I could have easily made a ton more money if I did all the procedures that patients were sent in for.
20. BE NICE! You would be surprised how many referring docs say the other pain guys were jerks to their patients.
21. Try to be associated with spine surgeons- they will have nearly 100% procedures, as opposed to primary care. Neurologists, podiatrists, and any surgical speciality (with the exception of neurosurgery and ortho spine) are bad referral sources.
22. Never do inpatient pain management- bad stuff and way too inefficient- it takes an act of God to get something done in a hospital.
23. Don't take ER referrals- almost always bad and they want to dump drug seekers on you.

#21, I would disagree. The ortho groups in my area either do their own injections in their own ASC, or rotate new pain grads out of training every 2 years in their own group, or send you all their bad failed back patients for trials and expect you to send them for implants regardless whether or not patients are good candidates.

 

[drpainfree]

BW15, you sounds like a reasonable guy...where are you planning to practice? PM if necessary. If I know any practice that might be hiring, I might direct you their way

 

[hyperalgesia]

This is depressing. You can make 400k as a starting salary doing anesthesia without a fellowship. Why would anyone choose to do pain if the market is truly like this?

Well you also have to use opioids in anesthesia...

 

[deleted993114]

Wow. My hat is off to you Hawkeye2009. I have been in practice probably as long as you have, albeit the first 8 years in academics. I have never come close to those numbers. Much of your advice is very helpful. Some of it applies to a different generation of doctors. Most guys from our era, my self excluded, wanted to work like dogs and make as much money as they could. Those are the guys in anesthesia practice who took as much call as they could, spent little time at home with family, but made $$$. I know lots of guys who went to those practices and are multi-multi-millionaires now and retired or working half time at 50 years of age. Today's docs seem to value quality of life over quantity of cash. They want to eat lunch like a human being and run out of the office at the end of the day rather than spend hours charting. Nothing wrong with that. You should not have to kill yourself to make a decent living in medicine. It may have come to that now but we should have not let it get to that point.

Regarding you comment about the need to be FAST. Do you think that recent grads are not fast because they lack experience or are poorly trained or over concerned with safety? I have witnessed docs do 6 cases per hour who have patients unconscious when then walk in the room and throw a needle in with little concern about where the tip is. Typically everyone gets a series of 3 so eventually at least one needle reaches the target. I have also witnessed 1 or 2 extremely experienced AND extremely talented docs who work with rock star techs and RNs in multiple rooms and can do 10 cases an hour. Their RNs run the RF machine and pull the needles out while the doc has moved on to the next patient in another room. Docs this good with staff this good are RARE. I'm all in favor of efficiency but the assembly line mentality that has permeated medicine is VERY VERY SAD.

With regard to prescribing opioids, most pain docs do it to keep people coming through the door. If you are in an ortho group your ortho partners want this to keep patients happy. Nothing works better to smooth over a bad outcome than a monthly supply of Percocet. It gets the nagging patient out of the surgeons office and that is what they want. The surgeon doesn't care what you do as long as they don't need to deal with the unhappy patient. Unfortunately if you don't prescribe opioids your practice suffers. I loose patients because of this. I just don't see the value in COT for 99.9% of patients. I don't see the maintenance of function, etc that many claim. I can't stomach the BS that goes along with patients on these meds.

I think that the younger guys are trained by academics who do not value speed, as they are on salary in an academic setting. Additionally, the younger guys don't have enough reps to be confident. Both combine to being slower.

I saw my own patients and "only" did about 24 procedures in the office every day, seeing 32 pts per day. I don't think it was an assembly line, as I would chat with each and every patient- no "directed" injections from midlevels.

I agree that you need to prescribe pain meds to keep the referral base happy. Regardless of the fantasy world of academics, the referral base wants help with these patients and refusal to do so can have consequences.

I am at a stage in my career where I don't want to work as hard. I even ate lunch last week on two days! Obviously, there is a balance between money and time off.