pain practice startup- few questions

[smarterchild]

I'm in the process of opening a pain practice (in MA) and had a few questions that I was hoping to get your advice on:

1. With regards to the C-arm, I've been looking at used GE OEC C-arms. It seems that even the used 9800 machines are upwards of $65000. I was able to locate a 9600 for less than $30k, which will fit more into my budget right now. Do you have any experience with the 9600 and will it be sufficient for the procedures that we do?

2. I spoke with a "healthcare attorney". He quoted me approximately 30 hours of time to do the following:
-establish PLLC
-Draft certificate of organization
-draft operating agreement
-employment agreements
-employee handbook
-HIPAA ( notice of privacy practices, business associate agreement, authorization to use PHI)
-Patient consents and agreements.

At $275 an hour, thats more than $8000 in legal fees. Does that sound reasonable to you? Is there anything else the attorney should be helping with me

3. Lastly, any recommendations of billing/credentialing companies?

Thank you so much

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[painfree23]

If I’m starting something, I’m really not sure if an investment in a c arm is worth it? Why not just take it to a asc and lease a smaller building space?

 

[powermd]

$8000 sounds insane for what will likely be a ton of boilerplate he already has on a USB key.

A lot of what you mention is just filling out applications and sending them to the correct addresses.

I would shop around on this!

 

[nvrsumr]

You need an attorney to draft ur operating agreement and his paralegal to go online and register the entity with the state. Rest u can rip from internet until u have the cash.

Look at refurbished c arm from Mfr and get the warranty- their lease to own rates aren’t terrible. Good tools are always worth it.

If u are purchasing property look at an Sba loan and roll everything into it.

 

[drusso]

Depends...billable hours suck...but, in some ways using him as a "turn key" solution can be insurance.

If this attorney is reliable and interested in keeping you as a client then it might not be a too bad a deal. If you have a contested wrongful termination and he's representing you with *his* employee handbook, he obviously has skin in the game...

If you like him, ask if he'll do the scope of work for a retainer arrangement...you'll pay him $2K per year for 5 years and he agrees to all start up activities and re-occuring delimitus work such as ensuring that your handbook and operating policies and procedures are annually updated, keeping the corporate minutes and shareholder meeting minutes, etc.

Otherwise, I agree with the other posters. A little elbow grease and discretionary effort can get this done. Just depends how much else you got going on...

 

[promethius]

If I’m starting something, I’m really not sure if an investment in a c arm is worth it? Why not just take it to a asc and lease a smaller building space?

Depends on how much capital you have and how much risk you are willing to take. If you are able to lease/own your own equipment and do the procedures in your office, you can collect the facility fees in addition to the professional fees. Otherwise, if you do the procedure at an ASC or hospital, all you will be able to collect is the professional fee. You can take a look at the annually updated fee schedules for pain procedures on ASIPP's website to see the breakdown of professional versus facility fees in different clinical settings; that should help you decide whether or not it is worth investing in your own equipment when you start off.

Regarding c-arms, I have heard of people getting quotes for as low as $40K for 9800 super Cs from third party sellers, but those are as-is without any warranty. If you go with third party sellers, I would recommend that you get a medical physicist to go over the c-arm for you before you buy unless you think you are technically competent to assess c-arms for any underlying problems. If you decide to purchase from the manufacturer GE OEC, you will not be able to purchase any refurbished 9600s because they are end-of-life. If you buy a 9600, just know that GE OEC will not service them either because they are end-of-life, but you can get a third party to do it for you if you run into any problems.

I was trained on a 9400, so yes, a 9600 should be more than adequate for performing the vast majority of pain procedures. The main differences between the 9600s and the 9800s are (1) the 9800s have better resolution than the 9600s (1K x 1K versus 512 x 512), (2) the 9800s have touch screen monitors whereas the 9600s do not have touch screen monitors, and (3) the 9800s are on average about 10 years newer than the 9600s. You should be able to negotiate a lower rate for refurbished 9800s because I heard of people getting them from GE OEC for as low as $55K with a one-year warranty included. You do not need the flat panels nor any software more advanced than ESP on it unless you have to have digital subtraction.

 

[Ducttape]

Prometheus, you are correct but your terminology could use a little refinement.

Office based procedures collect a global fee, not separate professional + facility fees that are generated at an ASC or hospital. The global fee includes both and is obviously higher than professional fee only.

I say this only so smarterchild is clear in the future on what he is collecting/can collect, because invariably there is the “why can’t I collect the facility fee in the office” question...

 

[smarterchild]

Thank you for all the replies! Very very helpful!

I didn’t realize the legal paperwork was something I would be able to do on my own. I don’t mind putting in the work myself at all. I’m working full time for someone else right now but I can find time to do it. Do you know of any resources online that would guide me through the process?

I spoke to GE directly and they were unwilling to budge from their price point of 65k. There’s a third party seller here in Massachusetts who will sell a used 9600 c arm with laser pointer and USB port, 1 year parts and labor warranty and OR table (used) for a little less than $40k + tax. I thought that seemed fair. Do you guys agree?

The other thing I’m having a hard time is finding someone to help me with credentialing and billing. Do you have any companies or groups you would recommend?

Thanks Again and have a great holiday!

 

[painfree23]

Prometheus, you are correct but your terminology could use a little refinement.

Office based procedures collect a global fee, not separate professional + facility fees that are generated at an ASC or hospital. The global fee includes both and is obviously higher than professional fee only.

I say this only so smarterchild is clear in the future on what he is collecting/can collect, because invariably there is the “why can’t I collect the facility fee in the office” question...

I really don’t think the cost of an in office c arm that allows u to bill that global fee will outweigh doing it in an asc and be able to bill for facility fee too

 

[drusso]

Prometheus, you are correct but your terminology could use a little refinement.

Office based procedures collect a global fee, not separate professional + facility fees that are generated at an ASC or hospital. The global fee includes both and is obviously higher than professional fee only.

I say this only so smarterchild is clear in the future on what he is collecting/can collect, because invariably there is the “why can’t I collect the facility fee in the office” question...

There is also a moral dimension to this decision. By choosing to invest in an office-based procedure suite and collecting a global instead of a pro fee plus facility fee you'll be opposing a corrupt site of service differential (SOSd(f)) system supported by Big Hospital & Health System MD's and used as a means of revenue of arbitrage that puts profits over patients.

Developing an office-based practice:

Your patients will see lower out of pocket expenses.
You will have more control and discretion with development of cash-based, concierge, and direct care service lines.
You will sleep better at night knowing that YOU are not "part of the problem" with price gouging and health care inflation in medicine.
And, given that MedPAC and other leading policy groups are getting wise to the employed health system MD/Big Hospital hustle, you'll ultimately be on the right side of history...

MedPAC suggests MIPS overhaul, more site-neutral payments

"The CMS has worked to level the playing field with proposals for site-neutral payment systems in the Hospital Outpatient Prospective and Ambulatory Surgical Center payment systems. The AHA has also opposed this movement, calling it short-sighted and inflexible."

 

[hyperalgesia]

I really don’t think the cost of an in office c arm that allows u to bill that global fee will outweigh doing it in an asc and be able to bill for facility fee too

You can't bill for a facility fee in an ASC unless you alone outright own the ASC. This is not usually a viable option for a startup practice. Keep in mind that many new businesses quickly run out of money and fail.

The typical path for a startup is to rent or share a small office and do procedures in an ASC or hospital for 3-6 months or so, only collecting the pro fees. During this time you can iron out some of the unknowns of the practice. Then you get your c-arm suite, etc.

Later, if all the financials look good and you are humming along and ambitious, some will look at investing in an ASC.

It's not crazy to start out with a c-arm suite but hopefully you have a solid handle on the situation before you start investing, taking out loans, etc.

 

[Ligament]

There is nothing wrong with taking your procedures to an ASC when you start up. Many advantages:
1. You hire much fewer staff
2. You don't have a procedure room
3. You don't need to buy a c-arm
4. You can operate out of a very small office space, or sublease from multiple locations (since you have no c-arm to house)

 

[painfree23]

There is nothing wrong with taking your procedures to an ASC when you start up. Many advantages:
1. You hire much fewer staff
2. You don't have a procedure room
3. You don't need to buy a c-arm
4. You can operate out of a very small office space, or sublease from multiple locations (since you have no c-arm to house)

This is what I was thinking. I do clinic procedures and it’s a pain in the ass with the small staff I have. Also, when one of my staff is in the back helping me, the phone calls are being missed.

The other thing to consider is that it gives the staff time to get prior auth, call insurance for procedures etc while ur at the asc doing procedures.

 

[Biohazard685]

Credentialing is a pain in the ass depending on your state. Much of it you can do on your own if you have down time to chase after phone calls. But if time is an issue then reach out to some of your referring physicians in the area to see if they know anybody.

 

[promethius]

Prometheus, you are correct but your terminology could use a little refinement.

Office based procedures collect a global fee, not separate professional + facility fees that are generated at an ASC or hospital. The global fee includes both and is obviously higher than professional fee only.

I say this only so smarterchild is clear in the future on what he is collecting/can collect, because invariably there is the “why can’t I collect the facility fee in the office” question...

Thank you for the clarification. There are newbies out there who may not know, so I just wanted to emphasize that the "facility fee" everyone talks about is not just for doing procedures in an ASC or hospital. You can collect that component as well for doing procedures in your office as part of the global fee. Of course the "facility fee" is higher if you do your procedures in an ASC that you OWN, but most start-ups will not have either the capital or the fortitude to be investing in an ASC from the get-go.

Regarding your c-arm, $40K for a refurbished 9600, used imaging table, and 1-year warranty is an okay deal. GE OEC charges about $10K for a 1-year service agreement and Philips charges about $6K for a 1-year service agreement. Having said that, third-parties usually charge less than the manufacturers. I have seen as-is 9600s for as low as $10K and as high as $30K with median price of $20K. Cost of imaging table depends largely on how many different motions it has. For pain management, 1 to 2 motions is all you need with height adjustment's being the most common motion. You should be able to buy a brand new 1-motion imaging table for $7-$9K with used ones running about half that price.

Regarding filing paperwork for articles of organization, you can do that on your own. Most people used a lawyer to do it 15 years ago because nothing was online, but nowadays, if you go to your secretary of state's website, you should be able to find and fill out the necessary forms and submit them online. It took me about 15-30 minutes, and I got approved in about 10 days without the need to go through a lawyer.

Regarding credentialing, you should check out the thread "starting own pain practice" I started a while back on this forum. Bronchospasm had a link to a credentialing company he used and recommended that charged $2K for 10 insurances. Of course, you can do the credentialing on your own as well if you have the time, but be warned, dealing with insurance companies is similar to dealing with the government in terms of how fast things get done.

 

[painfree23]

You can collect that component as well for doing procedures in your office as part of the global fee

What do u mean by this? The fact that professional fees are higher for clinic procedures?

 

[smarterchild]

Thank you for all the great Input!

Prometheus, do you know which companies are offering 9600s at such a low price. The company I found is local so thought that might make it easier for any future repairs. Do you think it’s worth it to buy from an out of state company?

Will definitely check out your other thread. Thanks again!

 

[Ducttape]

the global fee that you will collect for doing office based procedures will incorporate the separate professional and office based "facility fees" in to one amount, almost always higher than professional fee alone that one would get doing the procedure in ASC/hospital.

look at ASIPP website for concrete numbers.

ok ill give you numbers (now you can charge more than these numbers per procedure - these are what Medicare pays. most docs charge a multiple of this amount such as 2x, then get paid whatever has been arranged to be on an insurance companies panel).

Lumbar epidural - CPT code 62323, for ICD-10 code of M54.16, as an example.

Office based injection:
Final payment, all to physician: $250.56.

ASC based injection:
Final payment, to physician: $102.60.
Final payment, to ASC: $283.10
Final payment (by patient and insurance): $385.70

of course, the difference in these numbers are what is called the SOS differential. if you want more info on that, just do a search for "drusso" and "SOS differential"... or actually just do a search for "drusso"

 

[Ligament]

This is what I was thinking. I do clinic procedures and it’s a pain in the ass with the small staff I have. Also, when one of my staff is in the back helping me, the phone calls are being missed.

The other thing to consider is that it gives the staff time to get prior auth, call insurance for procedures etc while ur at the asc doing procedures.

I cannot emphasize enough how much easier it is to go to an ASC instead of having in house fluoroscopy when you are first starting out. Overhead will kill you and running a fluoro suite is a sure fire way to need a heck of a lot more staff and office space. I'm not saying its wrong either way, but you can enjoy a MUCH lighter footprint and sublease smaller offices...good way to start...

 

[Pain Applicant1]

I'm in the process of opening a pain practice (in MA) and had a few questions that I was hoping to get your advice on:

1. With regards to the C-arm, I've been looking at used GE OEC C-arms. It seems that even the used 9800 machines are upwards of $65000. I was able to locate a 9600 for less than $30k, which will fit more into my budget right now. Do you have any experience with the 9600 and will it be sufficient for the procedures that we do?

Buy the cheapest C-arm with at least a year warranty. You can upgrade later when you have more money to spend but you probably won't need to.

2. I spoke with a "healthcare attorney". He quoted me approximately 30 hours of time to do the following:
-establish PLLC
-Draft certificate of organization
-draft operating agreement
-employment agreements
-employee handbook
-HIPAA ( notice of privacy practices, business associate agreement, authorization to use PHI)
-Patient consents and agreements.

At $275 an hour, thats more than $8000 in legal fees. Does that sound reasonable to you? Is there anything else the attorney should be helping with me

Ridiculous. You can do all of this yourself. Just use google and spend an hour or two reading about this stuff. I have a few LLCs. I think it takes me about 5 minutes to create one.

3. Lastly, any recommendations of billing/credentialing companies?

Most importantly, learn and do billing yourself. Do NOT put this off. This will take time and patience but will be the best investment you can make. Once you have it down pat, you will learn why things get paid and why they get denied. Initially, I spent countless amounts of time on billing but I don't think I spend more than an hour per week on billing at this point. Your future self and your future bank account will thank you. Take it from me, I'm in my own practice for seven years. ALL billing companies are awful and will cost you. I don't necessarily blame the billing companies for being so bad, the set-up of the system causes this to be the case. It's just not in their best business interest to collect all of your money.

Thank you so much

 

[Agast]

I would get a sense of what the pain management culture is like in your area. In mine, everyone expects to be “knocked out.” Some of them look like I’ve grown a second head when I suggest they do a procedure under local anesthesia. It’s not worth it to me to take a stand because they’ll just go somewhere else. I’m employed and thought I’d eventually get my own in office set up but it probably wouldn’t go well because people here are willing to pay more to not feel an ounce of discomfort.

 

[painfree23]

I would get a sense of what the pain management culture is like in your area. In mine, everyone expects to be “knocked out.” Some of them look like I’ve grown a second head when I suggest they do a procedure under local anesthesia. It’s not worth it to me to take a stand because they’ll just go somewhere else. I’m employed and thought I’d eventually get my own in office set up but it probably wouldn’t go well because people here are willing to pay more to not feel an ounce of discomfort.

do you plan to do in office sedation? does that reimburse well?

 

[lobelsteve]

I would get a sense of what the pain management culture is like in your area. In mine, everyone expects to be “knocked out.” Some of them look like I’ve grown a second head when I suggest they do a procedure under local anesthesia. It’s not worth it to me to take a stand because they’ll just go somewhere else. I’m employed and thought I’d eventually get my own in office set up but it probably wouldn’t go well because people here are willing to pay more to not feel an ounce of discomfort.

Perpetuating nonsense. It is not the case. The troubles of getting a new consult. Telling the story to another doc, waiting two more weeks. Most, if not all will just hop on the table to get it over with.

Heck, over half my patients would pay cash for a tfesi if insurance precert not done.

 

[promethius]

Thank you for all the great Input!

Prometheus, do you know which companies are offering 9600s at such a low price. The company I found is local so thought that might make it easier for any future repairs. Do you think it’s worth it to buy from an out of state company?

Will definitely check out your other thread. Thanks again!

I just did a quick search on ebay. If you buy the c-arm out-of-state, you may avoid having to pay taxes on it, which can be quite substantial. Though you may have to figure out how to ship it to yourself if shipping is not included.

 

[pastafan]

I just did a quick search on ebay. If you buy the c-arm out-of-state, you may avoid having to pay taxes on it, which can be quite substantial. Though you may have to figure out how to ship it to yourself if shipping is not included.

True but there was a thread here a while back where that was done and C arm was defective. You can only imagine the hassle factor involved in that transaction.

 

[myrandom2003]

is an AED required in a private office? I assume a crash cart if in office procedure suite?
What other equipment do you guys feel is necessary to have in office?

Anyone have a good paperless office setup?

 

[Ducttape]

State dependent. For example, in NY all dental offices are required but doctors offices may not be.

Personally I would have an AED in the office (along with naloxone rescue kit) even if I did no injections at all.

 

[promethius]

True but there was a thread here a while back where that was done and C arm was defective. You can only imagine the hassle factor involved in that transaction.

You have a good recollection. There is a lot of hassle involved with purchasing a c-arm out-of-state. Most third-party sellers sell c-arms as-is to local sellers who in turn repair/repaint them, put a warranty on them, and sell them to physicians for a higher mark-up cost. You may be able to save $5-$10K by buying a c-arm directly from a third-party seller, but there is risk and hassle involved of making sure it's not a scam, as these transactions often involve wiring large amounts of funds; making sure the c-arm actually works; and finding a transport company to transport the c-arm to you. Buying a c-arm from one of these third-party sellers is similar to buying an expensive car from a stranger, but not being able to drive off with it right away after the funds exchange hands.

 

[lobelsteve]

It's a piece of equipment. Expensive toaster.
Go see the machine yourself in action. Rent a box truck from uhaul, hire 1-2 guys or get some friends and staff to move it on/off truck. Lots of blankets and tie down straps. It's not a race car.

 

[Cholula]

I just did a quick search on ebay. If you buy the c-arm out-of-state, you may avoid having to pay taxes on it, which can be quite substantial. Though you may have to figure out how to ship it to yourself if shipping is not included.

Depending on your state laws, you may pay consumer use tax, which is exactly the same as sales tax, on it if purchased without paying sales tax. Also you will be paying business property tax on it as you depreciate the property over five years. Someone from my state invited herself into my clinic making note of every taxable property I owned and verified that I reported everything correctly.

 

[lonelobo]

It's a piece of equipment. Expensive toaster.
Go see the machine yourself in action. Rent a box truck from uhaul, hire 1-2 guys or get some friends and staff to move it on/off truck. Lots of blankets and tie down straps. It's not a race car.

Probably not a good idea, if you have warranty through manufacturer(like I do with Phillips), as it would void it.

 

[drpainfree]

State dependent. For example, in NY all dental offices are required but doctors offices may not be.

Personally I would have an AED in the office (along with naloxone rescue kit) even if I did no injections at all.

if you are doing procedure in your office, you should get a real defib, not AED. You are much limited with an AED. Besides, you should be ACLS certified/recert every two years and running a code should be something you're comfortable with.

 

[lobelsteve]

if you are doing procedure in your office, you should get a real defib, not AED. You are much limited with an AED. Besides, you should be ACLS certified/recert every two years and running a code should be something you're comfortable with.

Completely disagree. I do acls every 2 years. 1 code like situation in 14 years. No meds, no compressions, no breaths needed.
AED is better choice than full defib.

 

[Ducttape]

AED is a lot less expensive, and does not require the inspections or upkeep.... I would favor the AED for that particular reason.

also, the expectations of having a full defib is that you are almost expecting a complication and require more exotic medication, as opposed to an "oops, we have a crash get the emergency AED please"...

 

[swamprat]

Any1 think it’s a bad idea to set up shop in a small office do procedures in an ASC to start out obviously they will take the facility fee u keep professional fee and then as u grow purchase c arm for in office ? Im trying to wrap my head around start up costs and that seems like the cheapest way to do things while learning the business side of things.

 

[Biohazard685]

Any1 think it’s a bad idea to set up shop in a small office do procedures in an ASC to start out obviously they will take the facility fee u keep professional fee and then as u grow purchase c arm for in office ? Im trying to wrap my head around start up costs and that seems like the cheapest way to do things while learning the business side of things.

Older c arms can be had for a bargain
All depends on practice circumstances.

 

[ssmallz]

Cashflow is king!!!! It means being able to pay your employees, it means being able to pay your rent, and it means being able to keep your practice up and running for another month. I'll say it again because it's that important, CASHFLOW IS KIIIIIING!!!!! And this goes triple for anyone starting out their practice. When you're first starting out your practice you're going to be slow so you're won't be making as much money as you expect. You will also have to lay out a lot of money because you're not going to get paid for at least a month for any work you do. You're number one goal should be survival and that means minimizing your monthly expenses. I would focus on a small office with limited staff, maybe even subleasing from a surgeon a few days a week. Staff will be your biggest expense when you start up and finding good staff can be tricky if you can't offer them full time hours. Staff is also incredibly important because your patients and referral sources will speak to them before they see you so if they aren't up to snuff then it will reflect poorly on you. I would outsource as much as possible to keep things simple and that means taking your procedures to a surgicenter. Focus on marketing and recruiting patients, that's the lifeblood of your practice and foundation for which all else will be built. Sure, you're not maximizing your income but you're also surviving. Once you become busy and have a steady stream of income, move into the bigger office and build that surgicenter/procedure room to maximize revenue.

 

[Hoya11]

Any1 think it’s a bad idea to set up shop in a small office do procedures in an ASC to start out obviously they will take the facility fee u keep professional fee and then as u grow purchase c arm for in office ? Im trying to wrap my head around start up costs and that seems like the cheapest way to do things while learning the business side of things.

I thought the best way was to do it all in an ASC at first and as you build, look to become a partner in that ASC.

 

[Ronin1]

You have to do the math for ASC ownership. What percentage can you buy and return on investment. What are the types of cases performed by others etc. and balance against doing everything in the office.