Opening a solo practice

[dr_ankle]

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Hello everyone,

I am in the process of opening my own solo practice, and wanted to see if anyone would have some advise for opening on their own. I decided at this point not to purchase an existing practice, as I have heard some not so great stories from friends who had done it and got burned (shady billing, medicare issues, etc). Also if anyone is willing to share how much they had to invest initially to open a practice, that would be greatly appreciated. I am looking to open a standard practice, a mix of some surgeries/mostly in office stuff. I am not necessarily concentrating on one particular area of podiatry. I already have a credentialing company working for credentialing, so I can be ready to start as soon as I have secured a location, but I want to make sure I am not missing any important points along the way.

Thanks

edit: Also, if there is anything that you did not expect while opening that you wish you knew beforehand, that would be very beneficial also

 

[wysdoc]

I'm going to send you to a thread where @Feli documents their process over time Costs and figures... startup Solo podiatry office

 

[dr_ankle]

I'm going to send you to a thread where @Feli documents their process over time Costs and figures... startup Solo podiatry office

Thanks! appreciate it 👍

 

[heybrother]

I'm working on a huge post on it, but my starting advice is just - ask AI to write you a huge plan. Its worth doing, but it will consume your life. I'm like 3-4 months into a new practice and am finally getting to the point where I don't have something new to work on every day.

My presumption if you are credentialing is you have already formed a LLC/PC, applied for EIN, written to the IRS for S-Corp, NPI2. Not sure the logistics of doing 855i with CMS/PECOS if you don't have a location yet. Real estate, liability insurance, malpractice insurance.

My advice is to starting doing your accounting/book keeping asap. I was months in before I got Xero and it took a lot of work/training/trying to get it right and learn it and its a lot easier to just be adding your receipts along the way instead of adding them from an Excel after the fact.

You'll be tempted to buy used equipment. It saves money, but it can blow up in your face. I just had a used Midmark chair I bought crap out and it was my "good chair".

I used PICA or whatever its called for my malpractice to avoid paying tail, but it turns out you can just switch from one malpractice to another so that's something to think about.

Realize that when you pay staff you have to pay their taxes also so don't just think payroll is $dollars-per-hour x hour. There's always going to be more to it.

Read up on 835s, ERA, EFTs, Medicare Advantage, copays, etc. Helps to know your local plans. Helps to understand what a good rate is. Know that you are going to have to negotiate - maybe your credentialing company does it for you. Some people are big believers in that - I'm not. No one cares more about your practice than you do. Use AI to write your internal company HR documents. Recognize you are supposed to have lots of plans for things like exposures to sharps, chemicals, etc.

Don't buy anything from a medical supply company until you speak to the rep they assign you. After I made a purchase the rep went through and dropped the prices on a bunch of the supplies I bought to make it competitive.

 

[dr_ankle]

I'm working on a huge post on it, but my starting advice is just - ask AI to write you a huge plan. Its worth doing, but it will consume your life. I'm like 3-4 months into a new practice and am finally getting to the point where I don't have something new to work on every day.

My presumption if you are credentialing is you have already formed a LLC/PC, applied for EIN, written to the IRS for S-Corp, NPI2. Not sure the logistics of doing 855i with CMS/PECOS if you don't have a location yet. Real estate, liability insurance, malpractice insurance.

My advice is to starting doing your accounting/book keeping asap. I was months in before I got Xero and it took a lot of work/training/trying to get it right and learn it and its a lot easier to just be adding your receipts along the way instead of adding them from an Excel after the fact.

You'll be tempted to buy used equipment. It saves money, but it can blow up in your face. I just had a used Midmark chair I bought crap out and it was my "good chair".

I used PICA or whatever its called for my malpractice to avoid paying tail, but it turns out you can just switch from one malpractice to another so that's something to think about.

Realize that when you pay staff you have to pay their taxes also so don't just think payroll is $dollars-per-hour x hour. There's always going to be more to it.

Read up on 835s, ERA, EFTs, Medicare Advantage, copays, etc. Helps to know your local plans. Helps to understand what a good rate is. Know that you are going to have to negotiate - maybe your credentialing company does it for you. Some people are big believers in that - I'm not. No one cares more about your practice than you do. Use AI to write your internal company HR documents. Recognize you are supposed to have lots of plans for things like exposures to sharps, chemicals, etc.

Don't buy anything from a medical supply company until you speak to the rep they assign you. After I made a purchase the rep went through and dropped the prices on a bunch of the supplies I bought to make it competitive.

Thank you! This is such a detailed post it's very ,very helpful.

"My presumption if you are credentialing is you have already formed a LLC/PC, applied for EIN, written to the IRS for S-Corp, NPI2. Not sure the logistics of doing 855i with CMS/PECOS if you don't have a location yet. Real estate, liability insurance, malpractice insurance." yes so far I have formed the LLC/have the EIN/NPI2. My credentialing company was able to attain the medicare credentialing through my home address, I was concerned about doing that, but from what I understand it'll be an easy switch once I have secured a location. I am looking at a few different ones and finalizing details. I do have malpractice, liability I was planning on attaining as soon as I sign a lease for a company.

If you don't mind me asking, what was your initial financial spending for the practice? At three months, are you seeing a decent amount of patients yet that you are not bleeding as much from your own pocket?

 

[Boba Foot]

You shouldn’t use your home address for LLC, NPI or type 2 NPI, that’s public-facing info. You can use a registered agent for LLC but not NPIs. You need a location pretty early in the procsss, like yesterday. Or at least have a tentative location that you’re in the process of signing a lease on.

I’m currently in the process of signing on with an IPA and they require an address for most credentialing, especially Medicare.

 

[Boba Foot]

Also what @heybrother said— make good friends with Claude or Gemini, they will make the startup process much easier to navigate. ChatGPT is hot garbage though.

 

[heybrother]

Thank you! This is such a detailed post it's very ,very helpful.

"My presumption if you are credentialing is you have already formed a LLC/PC, applied for EIN, written to the IRS for S-Corp, NPI2. Not sure the logistics of doing 855i with CMS/PECOS if you don't have a location yet. Real estate, liability insurance, malpractice insurance." yes so far I have formed the LLC/have the EIN/NPI2. My credentialing company was able to attain the medicare credentialing through my home address, I was concerned about doing that, but from what I understand it'll be an easy switch once I have secured a location. I am looking at a few different ones and finalizing details. I do have malpractice, liability I was planning on attaining as soon as I sign a lease for a company.

If you don't mind me asking, what was your initial financial spending for the practice? At three months, are you seeing a decent amount of patients yet that you are not bleeding as much from your own pocket?

I'm well over $100K but my finances are much more complicated than most people's because I bought the building also. $55K down on the building, $7K paint job and various repairs. Spent $60K on my personal credit card getting the practice set-up before switching over to the business. Didn't charge the practice rent for like 2 months so that's money out of 1 pocket for the other. Had to infuse both real estate LLC and practice LLC. Got stuck paying my full malpractice premium 1 month into practicing. Had to infuse cash to start for things like payroll. Probably at least $25K there.

I bought whatever I thought I needed- I wasn't aiming for a $40K start because I'm in the same town, down the street from my original practice, and hoping to get going asap. I wanted a practice where people immediately knew we ready to go. Have been saving money like crazy over the years. Haven't ever taken a vacation since being a podiatrist. Paid off cars, public school for the kids. Paid for 2 staff off the get go which was painful, but immediately working out. One of my staff (MA) knew ECW enough to room patients. The other has gone crazy and figured out everything related to billing, posting, statements, ERA, etc. I'm not paying a billing company - we do all our own payment processing and we're working on collecting money up front to reduce statement costs, losses, etc. I have ZERO "percent contracts" where someone gets a cut of my money other than Helcim/credit card payor.

Haven't had to put cash in in months - think July was the last infusion. Seem to be approaching 15-19 patients a day though I think some of that is just not being there on a Friday because of CME/seeing family. Took my first paycheck this last cycle ($5K), but set it to only be once per month. Own the building so I'm basically paying myself there. Mortage is $2K, but rent payment is $5K. As the bank account increases I move towards moving the money into my pocket.

That said - still haven't broken $30K in collections yet. I occasionally have moments of anxiety, but I remain committed to doing it better than my last office. Collecting up front. Owning the real estate. Controlling EHR costs etc. Hiring another staff member tomorrow.

 

[dr_ankle]

You shouldn’t use your home address for LLC, NPI or type 2 NPI, that’s public-facing info. You can use a registered agent for LLC but not NPIs. You need a location pretty early in the procsss, like yesterday. Or at least have a tentative location that you’re in the process of signing a lease on.

I’m currently in the process of signing on with an IPA and they require an address for most credentialing, especially Medicare.

The public info is a little concerning for sure, but I was able to get credentialing pretty fast with most major plans, I think minus one or two. As per the credentialing company it's a quick switch over once the location is set. My plan was to start seeing patients on my own for nursing homes to get a stable income while I set up the practice, but that is a whole separate issue that I posted on here...still trying to get a lead on that but having a hard time getting any returns from outreach to the facilities. So the location was due to that. Hopefully it'll be an easy switch once I have my physical location.

 

[dr_ankle]

Also what @heybrother said— make good friends with Claude or Gemini, they will make the startup process much easier to navigate. ChatGPT is hot garbage though.

I will try those, I have been paying for chatGPT plus but not sure if it was worth it lol

 

[dr_ankle]

I'm well over $100K but my finances are much more complicated than most people's because I bought the building also. $55K down on the building, $7K paint job and various repairs. Spent $60K on my personal credit card getting the practice set-up before switching over to the business. Didn't charge the practice rent for like 2 months so that's money out of 1 pocket for the other. Had to infuse both real estate LLC and practice LLC. Got stuck paying my full malpractice premium 1 month into practicing. Had to infuse cash to start for things like payroll. Probably at least $25K there.

I bought whatever I thought I needed- I wasn't aiming for a $40K start because I'm in the same town, down the street from my original practice, and hoping to get going asap. I wanted a practice where people immediately knew we ready to go. Have been saving money like crazy over the years. Haven't ever taken a vacation since being a podiatrist. Paid off cars, public school for the kids. Paid for 2 staff off the get go which was painful, but immediately working out. One of my staff (MA) knew ECW enough to room patients. The other has gone crazy and figured out everything related to billing, posting, statements, ERA, etc. I'm not paying a billing company - we do all our own payment processing and we're working on collecting money up front to reduce statement costs, losses, etc. I have ZERO "percent contracts" where someone gets a cut of my money other than Helcim/credit card payor.

Haven't had to put cash in in months - think July was the last infusion. Seem to be approaching 15-19 patients a day though I think some of that is just not being there on a Friday because of CME/seeing family. Took my first paycheck this last cycle ($5K), but set it to only be once per month. Own the building so I'm basically paying myself there. Mortage is $2K, but rent payment is $5K. As the bank account increases I move towards moving the money into my pocket.

That said - still haven't broken $30K in collections yet. I occasionally have moments of anxiety, but I remain committed to doing it better than my last office. Collecting up front. Owning the real estate. Controlling EHR costs etc. Hiring another staff member tomorrow.

It sounds like a lot of work for now while you are starting out, but very smart for you in the long run. That is my goal, but I think for now just setting up the practice will be my big jump for the foreseeable future. I am happy that you turned it around so fast. You are the second person I read about who was able to get patients from the get go. I wish you the best of luck with your first full year 🤞

When you mention the 30K in collections, do you mean for the time you've been open? You said 4 months right?

And I get where you are coming from about doing things differently than your last office - the last practice I worked for was doing things that I felt sincerely uncomfortable about. Doing it yourself and doing it correctly may be tough initially, but I am sure pays off in the long run.

 

[heybrother]

I mean per month. I think total revenus is $90ishK. I'm still learning my software and it seems I haven't set Helcim/Square to allocate as "Service Revenue".

The thing that kills me for new podiatrists starting out is that if you can't see how billing/rates are handled you won't know enough about what we get paid to set-up your own practice in the future. The Medicare anchor will just weigh you down.

 

[Boba Foot]

I will try those, I have been paying for chatGPT plus but not sure if it was worth it lol

I use both Claude and Gemini. Each has things they’re better at and sometimes I cross check the two.

ChatGPT tends to just spam a bunch of word vomit and some of it is right and some of it is junk.

ChatGPT is kind of like the kid in the back of the classroom that talks a bunch and sounds confident so people think they’re smart even though they’re kind of a ****. Claude is the smart, bookish kid that is good at data and coding. Gemini is the all purpose smart person, better at marketing and scraping info off the internet but sometimes bugs out.

 

[Weirdy]

Thank you! This is such a detailed post it's very ,very helpful.

"My presumption if you are credentialing is you have already formed a LLC/PC, applied for EIN, written to the IRS for S-Corp, NPI2. Not sure the logistics of doing 855i with CMS/PECOS if you don't have a location yet. Real estate, liability insurance, malpractice insurance." yes so far I have formed the LLC/have the EIN/NPI2. My credentialing company was able to attain the medicare credentialing through my home address, I was concerned about doing that, but from what I understand it'll be an easy switch once I have secured a location. I am looking at a few different ones and finalizing details. I do have malpractice, liability I was planning on attaining as soon as I sign a lease for a company.

If you don't mind me asking, what was your initial financial spending for the practice? At three months, are you seeing a decent amount of patients yet that you are not bleeding as much from your own pocket?

Medicare 855i needs physical business address that is verifiable by USPS

"All reported practice location addresses must be a specific street address as recorded by the United States Postal Service. Your practice location must be the physical location where you render services to Medicare beneficiaries. Your practice location address cannot be a Post Office (P.O.) Box."

Here's a link to the form itself: https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms855i.pdf