license yes, but no BE/BC; options?

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oracalis

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I only completed one year of residency, then left (my choice). Went and got a Master's degree past 2 years. Having a hard time facing a return to residency (FP). I do have an unrestricted state medical license. Any ideas of my clinical options? I know what I can do non-clinically; also know that most clinical jobs require BE/BC. I suppose that correctional facility medicine is one option, and some Urgent Care places. Any ideas on private practice? I would only be interested in practicing in a field related to my Masters (further residency training would add little/nothing to my knowledge of this specific field). Would there be trouble with legally opening a practice, or with getting malpractice insurance?
Any/all advice much appreciated.

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theoretically, you could join a group practice. if the group sees you as fit for working with them, they secure the malpractice insurance and establish the contracts with the necessary entities.

as far as opening a practice on your own, you're at a disadvantage (assuming you can secure the financial capital) not being board eligible/certified in regards to securing contracts to get patients through hmos/insurance as well as malpractice insurance... but that's not to say that it's impossible.

edit: your best bet is to talk with someone with experience in establishing or helping to establish medical practices- someone with an master's in health administration who may better understand/know the intricacies of healthcare in your area. after all, just because you want to open your own practice, doesn't mean that you should as it may not be economically viable.
 
Thanks for the advice.
To be more specific, my Master's was in tropical medicine. I would like to open a travel medicine clinic---very low-tech, small practice, basically preventive med for people going overseas. Insurance companies wouldn't be an issue, as they generally do not reimburse for this anyway, so would be cash-only. Leaving aside the issue of profitability (difficult, I know), I think that the main issue would be malpractice. So, does anyone know if non BC/BE physicians have difficulties, or pay more, for malpractice insurance? And, is there any legal reason that I would not be able to open this type of practice?
Thanks for any insight you can provide.
 
Thanks for the advice.
To be more specific, my Master's was in tropical medicine. I would like to open a travel medicine clinic---very low-tech, small practice, basically preventive med for people going overseas. Insurance companies wouldn't be an issue, as they generally do not reimburse for this anyway, so would be cash-only. Leaving aside the issue of profitability (difficult, I know), I think that the main issue would be malpractice. So, does anyone know if non BC/BE physicians have difficulties, or pay more, for malpractice insurance? And, is there any legal reason that I would not be able to open this type of practice?
Thanks for any insight you can provide.

It is legal for a licensed physician to open a clinic in virtually any state. If you aren't BC/BE, it's hard to get reimbursed by insurance companies or medicare. If you aren't looking for reimbursement from these entities, your only problem is malpractice insurance or defending yourself in a lawsuit if something goes wrong.
 
I think you'd be able to get med mal insurance. I don't know if you'd pay more or not. I suspect that most insurers wouldn't have a specific program for a travel clinic and would lump you in with either primary care of urgent care. In reality your liability should be low. You would be presumably following CDC guidelines so you could fall back on that if there's a problem. Your main risks will be from people who have reactons to the meds and people who get sick despite your efforts. Either of these can be helped by good info/disclaimers.

As for profitability your main issue will be volume. You may or may not be incompetition with other docs and PMDs for this in the area you choose. I suggest picking an area near a busy intl airport. Plan on being available 24/7 while you get the practice going and cater to people who have to make unplanned trips. You could charge accordingly. Make your practice known to all the local travel agents, airlines. Make sure you have a website that will get indexed by the big search engines so that people who buy tickets on line and then search for travel med will find you.
 
Btw, you don't have to be BE/BC in order to participate in medicare (the goverment can't require you to become member of a 'guild' in order to contract with them).

They do however require that you tell them how call coverage for your patients is going to be arranged. In your 1-man GP practice, that could be a sticking point.

In your particular situation, you might be better off NOT becoming a medicare provider. If you don't contract with them, they have no say over your fee schedule. If you want to charge double to see a patient on sunday, you are free to do so. If you decide to sell your vaccines with a markup but give your professional service for free (the corporate optometry or undertaker model of business), you can do so. If you contract with medicare, they will tell you what you can and can't do (mostly in the can't category).
 
I think you'd be able to get med mal insurance. I don't know if you'd pay more or not. I suspect that most insurers wouldn't have a specific program for a travel clinic and would lump you in with either primary care of urgent care. In reality your liability should be low. You would be presumably following CDC guidelines so you could fall back on that if there's a problem. Your main risks will be from people who have reactons to the meds and people who get sick despite your efforts. Either of these can be helped by good info/disclaimers.

As for profitability your main issue will be volume. You may or may not be incompetition with other docs and PMDs for this in the area you choose. I suggest picking an area near a busy intl airport. Plan on being available 24/7 while you get the practice going and cater to people who have to make unplanned trips. You could charge accordingly. Make your practice known to all the local travel agents, airlines. Make sure you have a website that will get indexed by the big search engines so that people who buy tickets on line and then search for travel med will find you.

All this is good advice. You might also look at other "cash" for service care. One is DOT and insurance physicals. These are usually pretty good as well. Organized medicine and the ABMS has done its very best to finish off the ole fashioned GP, but if you are willing to forego the insurance panel issues and work on a cash basis, with low overhead, you might be able to make a go of it.

As others have stated, the biggie is the capital resources to get the practice going, covering the initial overheads which include rent/utils/taxes/equipment/insurances (property/injury/medmal) and putting bread on the table. In a startup practice, you may be able to get by without any staff, if you are willing to be the drawer of blood, runner of lab tests and follower up of scheduling a phone calls. This gets old in a hurry, but it's a way to start.

I've run the numbers in the past based on the typical hmo copays in the area. Here's the basic numbers from a nearby clinic (my best guess since I don't have them at my fingertips).

Office visit (int/prob focused new patient) $125
Office visit (int/prob focused return patient) $70
DoT physical $100

Plus you can bill for other services as well.
If you work in a big MC area and are not on their panel life becomes a tad more interesting. Depending on if they are open panel or not you might or might not be considred a primary care doc for the purpose of referals for secondary care, at least in some states. As always your mileage may vary.

But I've often thought of this. If a GP doc not on an insurance panel decided to charge a typical HMO/Insurance co-pay and built a busy practice, of say 9 hours a day with on the average 3 patients/hour, that would bring in 9x3x$25-$50 (in our area that's what copays are these days) or around $1000/day or $20,000 / month. Subtract about $5000 of that for overheads and that leaves you with $15,000/month. A nurse/assistant costs you $5,000 which leaves you with $10,000 x 11 months or $110,000, just from charging the co-pay amount, assuming you can collect it all. You don't have a medical office biller. You don't have insurance collections chasers and those are big expenses. You or your nurse answer the phone, and it's a real 'mom and pop' operation.

On the other hand, if you were able to bill *and* collect on the "list" price, $125 ($50 copay, $75 from insurance companies, less the negotiated discounts, of course), you might make an extra Jefferson or two an hour so we add $10k/month. So, you make a lot more, but some copays won't happen, some insurance companies will make you wait months, and you now need someone to argue with the insurance companies who don't have you on their panel, at a cost of an additional $5k in wages, extra telephones, faxes, computers etc, so you net out $5k/month or $60k/year.

Capital costs up front are not going to be free, of course. You need supplies, instruments and such, but it is doable. If you go the Medicare route, that opens up some too, but check carefully the costs of doing business with the government. It ain't cheap! Plus you get a bit more for doing office procedures, too.

As for folks with insurance, you can offer to help them with insurance forms, but do not get sucked into the direct pay/direct bill routine, in my opinion. This opens the door for insurance companies to a.) exclude you from the panel, b.) control the finances of your practice.

As you grow more effective/efficient, you'd probably be able to do a little better than this, but then your costs will also grow along with your practice. You might have more issues getting hospital admitting privs without BC/BE, too, depending on your locale, but then they do have hospitalists don't they?
 
Thanks everyone for the advice. It is not easy to get info from other docs regarding this, as many are somewhat hostile to the idea of general practice. However, like I mentioned above, I am seeking to open a different sort of practice, mainly travel med. I have been looking into the newish trend of micropractices, and this seems appealing to me---small office, no staff, no insurance companies (so little paperwork), see fewer patients but for longer visits. The regular way of primary care med (loads of patients, paperwork, and the bottom line) just does not appeal to me, and I would be very happy to spend more time with less patients, and make much less money ($40,000 profit/year would be satisfactory). Even with this low goal, though, it will not be easy to go against the norm.
 
Thanks everyone for the advice. It is not easy to get info from other docs regarding this, as many are somewhat hostile to the idea of general practice. However, like I mentioned above, I am seeking to open a different sort of practice, mainly travel med. I have been looking into the newish trend of micropractices, and this seems appealing to me---small office, no staff, no insurance companies (so little paperwork), see fewer patients but for longer visits. The regular way of primary care med (loads of patients, paperwork, and the bottom line) just does not appeal to me, and I would be very happy to spend more time with less patients, and make much less money ($40,000 profit/year would be satisfactory). Even with this low goal, though, it will not be easy to go against the norm.

If all you want is $40k, you could do some Urgent Care moonlighting on the side and do travel medicine as a hobby. There are motivated guys who make more than that moonlighting in residency.
 
Go take a Botox class and run an all Cash aesthetic clinic. Or you can be an out of network provider for insurance companies and just give the patient a superbill and let them deal with it. Take a credit card up front, charge them, and let them get reimbursed, it's their policy anyway, not yours. Just make sure you document and code correctly or the patient might get pissed and drop you.

There are a couple of physicians in town here who do that. They see a patient every 30 min and charge $125 cash or $250 for an hour visit. They have a lady that answers the phone and that's it. They are always full. Insurance is about 10K a year. You do the math, certainly more than 40K a year...
 
In your particular situation, you might be better off NOT becoming a medicare provider. If you don't contract with them, they have no say over your fee schedule. If you want to charge double to see a patient on sunday, you are free to do so.

If you decide to sell your vaccines with a markup but give your professional service for free (the corporate optometry or undertaker model of business),

I don't believe this is accurate. If someone decides not to accept Medicare assignment, nonetheless they have to participate to a degree with Medicare. There is not an opt-out. Whether or not you accept assignment, your lowest standard fee has to be given to Medicare patients (although special arrangements can be made with hardship cases on an individual basis). Whether or not you accept Medicare assignment, I believe you have to submit claims for any patients you treat that are Medicare patients if you provide a service for them that is normally covered by medicare. I think the only way you can avoid following the "limiting charge" for a service is if it is a service typically not covered by Medicare (which is rare to find). So with Medicare patients there is a limiting charge to what you can charge on a service - and you have to be careful giving anything free to a Medicare patient. You cannot give away free services to "entice" a Medicare patient to become a new patient.

Also, if you typically give a service away as free to any broad group of patients you cannot then charge another group a fee (especially a group covered by insurance), as that is seen as a two fee system.
 
I only completed one year of residency, then left (my choice). Went and got a Master's degree past 2 years. Having a hard time facing a return to residency (FP). I do have an unrestricted state medical license. Any ideas of my clinical options? I know what I can do non-clinically; also know that most clinical jobs require BE/BC. I suppose that correctional facility medicine is one option, and some Urgent Care places. Any ideas on private practice? I would only be interested in practicing in a field related to my Masters (further residency training would add little/nothing to my knowledge of this specific field). Would there be trouble with legally opening a practice, or with getting malpractice insurance?
Any/all advice much appreciated.

I believe if you are licensed in any one state, you can work in any state nationwide in a federal program such as the VA, IHS, USDA, or federal prisons. I am not sure if the VA requires BE/BC. Prisons did not seem that bad when I did rotations there - you are one of the people that prisoners seem to like. Just shift work - if I remember right all emergencies at night just go to the local hospital. I think they were paying right around $90,000 for someone to work 5 days a week. The secretary was a prison gaurd, who seemed to lack much etiquette.
 
I don't believe this is accurate. If someone decides not to accept Medicare assignment, nonetheless they have to participate to a degree with Medicare.

There are two ways of not participating in medicare:

- If you just don't enroll, you still have to provide your service to any beneficiary at medicare prices. The patient then has to re-coup his money from the local carrier.

- If you actively opt-out (submit a sworn affidavit to your medicare carrier that you don't accept assignments), you are now free to charge them whatever you deem appropriate. You just have to make a private contract with each and every medicare covered patient that spells out that you are not participating and that the patient will have to pay out of pocket and won't be able to submit his claim to medicare or medicare +. You better file those contracts in a well secured place, the feds don't like docs who don't submit to their grasp. If you provide emergency care to a medicare beneficiary (who would not be 'free' to sign your private contract), you can only charge medicare fees.

If you actively opt-out, you are excluded from participating in medicare for 2 years.

https://www.noridianmedicare.com/p-medb/enroll/general/opt_out.html
Medicare carriers manual (p23ff):
http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf
 
All this is good advice. You might also look at other "cash" for service care. One is DOT and insurance physicals. These are usually pretty good as well. Organized medicine and the ABMS has done its very best to finish off the ole fashioned GP, but if you are willing to forego the insurance panel issues and work on a cash basis, with low overhead, you might be able to make a go of it.

As others have stated, the biggie is the capital resources to get the practice going, covering the initial overheads which include rent/utils/taxes/equipment/insurances (property/injury/medmal) and putting bread on the table. In a startup practice, you may be able to get by without any staff, if you are willing to be the drawer of blood, runner of lab tests and follower up of scheduling a phone calls. This gets old in a hurry, but it's a way to start.

I've run the numbers in the past based on the typical hmo copays in the area. Here's the basic numbers from a nearby clinic (my best guess since I don't have them at my fingertips).

Office visit (int/prob focused new patient) $125
Office visit (int/prob focused return patient) $70
DoT physical $100

Plus you can bill for other services as well.
If you work in a big MC area and are not on their panel life becomes a tad more interesting. Depending on if they are open panel or not you might or might not be considred a primary care doc for the purpose of referals for secondary care, at least in some states. As always your mileage may vary.

But I've often thought of this. If a GP doc not on an insurance panel decided to charge a typical HMO/Insurance co-pay and built a busy practice, of say 9 hours a day with on the average 3 patients/hour, that would bring in 9x3x$25-$50 (in our area that's what copays are these days) or around $1000/day or $20,000 / month. Subtract about $5000 of that for overheads and that leaves you with $15,000/month. A nurse/assistant costs you $5,000 which leaves you with $10,000 x 11 months or $110,000, just from charging the co-pay amount, assuming you can collect it all. You don't have a medical office biller. You don't have insurance collections chasers and those are big expenses. You or your nurse answer the phone, and it's a real 'mom and pop' operation.

On the other hand, if you were able to bill *and* collect on the "list" price, $125 ($50 copay, $75 from insurance companies, less the negotiated discounts, of course), you might make an extra Jefferson or two an hour so we add $10k/month. So, you make a lot more, but some copays won't happen, some insurance companies will make you wait months, and you now need someone to argue with the insurance companies who don't have you on their panel, at a cost of an additional $5k in wages, extra telephones, faxes, computers etc, so you net out $5k/month or $60k/year.

Capital costs up front are not going to be free, of course. You need supplies, instruments and such, but it is doable. If you go the Medicare route, that opens up some too, but check carefully the costs of doing business with the government. It ain't cheap! Plus you get a bit more for doing office procedures, too.

As for folks with insurance, you can offer to help them with insurance forms, but do not get sucked into the direct pay/direct bill routine, in my opinion. This opens the door for insurance companies to a.) exclude you from the panel, b.) control the finances of your practice.

As you grow more effective/efficient, you'd probably be able to do a little better than this, but then your costs will also grow along with your practice. You might have more issues getting hospital admitting privs without BC/BE, too, depending on your locale, but then they do have hospitalists don't they?

Go take a Botox class and run an all Cash aesthetic clinic. Or you can be an out of network provider for insurance companies and just give the patient a superbill and let them deal with it. Take a credit card up front, charge them, and let them get reimbursed, it's their policy anyway, not yours. Just make sure you document and code correctly or the patient might get pissed and drop you.

There are a couple of physicians in town here who do that. They see a patient every 30 min and charge $125 cash or $250 for an hour visit. They have a lady that answers the phone and that's it. They are always full. Insurance is about 10K a year. You do the math, certainly more than 40K a year...

I find the idea of an "off the insurance radar" GP practice very interesting, especially the aspects of having longer patient visits and just charging fee for service. Can anyone point me toward some other threads where this is discussed more?

Thanks!
 
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