Private Practice: Out of Network Provider

[Nonphysiologic]

Hey,

I am starting a practice but after running some numbers it seems like you basically have to run an extremely high volume practice (bordering mill status) to have a profitable practice. I'd like to be a little more boutique and cutting edge. I was wondering how feasible would it be to only be out of network for PPOs and Medicare? I know some other docs in my area doing this and they all seem to be doing very well but i cant figure out if its because they have good reputations an internet presence.

Also why would a patient see a doctor that is out of network and potentially pay a higher deductible.

Final question: I heard from another doctor here that due to the ACA deductibles are negotiable due to economic hardship. So for example, if I see patient JOE SMITH as an out of network provider and his deductible is 4,000 and he is hesitant to pay me $4,000 out of pocket because that's what i charge for an epidural he is able to pay me say...$100.00 and i can accept that then he can call the insurance company and say that he can't pay the $4,000 and he can only afford $100.00 due to economic hardship and the insurance will accept and then when I bill the $4,000, $3,900 will be coming from the insurance company. (FYI This seemed like complete BS and Ive never heard of that and I asked several billers and people i know in the insurance world but this other doc swears he does it all the time and thats the key to get the out of network patients through the door). Any one else hear of this before? Again, seems like complete BS

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[SSdoc33]

in my experience, people see OON providers because they dont know they are out of network until they get a 5K bill that just appears in their mailbox.

either that, or it is a automobile/lawyer/PIP/chiro racket. tread lightly.

we all want to make more money with less work. just make sure you dont go too far over to the dark side

 

[Ducttape]

don't.

because the wrath of drusso will fall upon you.

and also because you are manipulating the system.

 

[Agast]

You can make a profit being in-network. It’s just not a great one. I think next year there will be a lot of office visit upcoming since reimbursement improved.

 

[Pain Applicant1]

I have my own practice and I know how to make a practice very profitable. I can walk you through the process step by step but I would not sleep well at night if I gave you any advice as I would never support someone who gave the example that you gave.

Not to judge too harshly but anyone who is bringing in $4000 for an epidural should probably be jailed.

 

[Nonphysiologic]

Yeah I agree. Seemed super shady to me as well.

I have my own practice and I know how to make a practice very profitable. I can walk you through the process step by step but I would not sleep well at night if I gave you any advice as I would never support someone who gave the example that you gave.

Not to judge too harshly but anyone who is bringing in $4000 for an epidural should probably be jailed.

 

[Ducttape]

I have my own practice and I know how to make a practice very profitable. I can walk you through the process step by step but I would not sleep well at night if I gave you any advice as I would never support someone who gave the example that you gave.

Not to judge too harshly but anyone who is bringing in $4000 for an epidural should probably be jailed.

in OP defense, he is asking about feasibility and not actually implementing any changes that include OON....

now is the time to talk to him to convince him of the folly of this line of thinking.

 

[westcoastresdoc]

I worked for a group where the they would see a lot of OON patients. They had a deductible but "would never be charged for it". For example, patient would come in, be evaluated, have injections or procedures done, and the insurances would be billed. The practice would never take their out of pocket expense and send it to insurance directly. at times, the patient's would get a reimbursement check and billing department would tell the patient ahead of time, that those checks must be sent to the practice and paid with the practice. Injections would reimburse in the thousands and anesthesia.. in the 10s of thousands at times. Surgery... yea..

I was told that this was legal but who knows. I would like to know what all of your experiences are on this.

 

[ateria radicularis magna]

I have heard of this kind of thing too and it would be great if someone on here can shine a light on this. What is going on? How is this possible?

 

[SandmanMD]

I have heard of practices doing this. I’m not sure how they are specifically billing and how they are getting away with that.

 

[drusso]

I have heard of this kind of thing too and it would be great if someone on here can shine a light on this. What is going on? How is this possible?

The whole thing just works more seamlessly if you put a lien against their house too. That way if they don't pay or send you the check from the insurance company you just evict them and sell their house for the proceeds or garnish their wages. Non-profit hospitals do this all the time.

UVA Health Still Squeezing Money From Patients — By Seizing Their Home Equity - KFF Health News

The University of Virginia promised reforms but has stopped short of announcing them, while hospital giant VCU Health has freed tens of thousands from property liens.

khn.org

Be clear: Look the patient in the eye and say, "You're f*cking going to pay me $4,000 for this epidural or I'm taking your house."

 

[Sushirolls]

Psych here...
There is nothing wrong with having OON practices. But in today's political climate you will need to spend extra time up front with a simple clear form that points out that you are OON and what that can mean for the patients expenses. Have examples on this form. Have people sign it.

Then you will need to decide if you are submitting the bills to the insurance company yourself as OON, or simply giving a super bill to the patient and having them submit it.

You can also do an in network / OON blend. Get in network with better paying insurance, and stay out of network for less ideal insurance, but again this has to be very clear and upfront with patients with real expected costs laid out before them.

Submitting claims to insurance adds to overhead, you need time to submit, and people to follow up on the hiccups that happen along the way. You might be able to reduce your overhead, which could mean a lower out of pocket list price for procedures by not being in network, and not submitting claims to insurance companies. This is done with various other specialties.

 

[Sushirolls]

Go to this thread:

Private Practice in Progress

Building a private practice, N of 1. Enjoy. Month zero: Grand plan was to use money from inpatient gig where independent contractor doing own billings to expedite insurance paneling, so all I had to do was switch over the practice address once opened. Long story short, not a quality place I...

forums.studentdoctor.net

Post #196 is a good summary of the steps to open your own practice, but some customization will be needed for a Pain practice. But its a good primer to get things planned out.

 

[myrandom2003]

You have to collect or attempt to collect the patient portion.

If you do not and insurance company finds out then they don’t have to pay you a penny. They can also file legal claim against you for fraudulent billing as well as drop you from credentialed (not same as contracted) panel.

Attempt to collect means = sending three statements to pay

 

[promethius]

Is there any benefit for patients to go out-of-network? Seems like it would happen only by accident when a patient would not know they are being treated by an out-of-network physician.

Other than ultimately holding patients responsible for the charges and/or balance billing them, would insurance companies actually pay more for the same services when physicians are out-of-network than when they are in-network? From my experience dealing with insurance companies that are out-of-network, they seem to discourage patients from going out-of-network by (1) requiring prior authorizations before any services can be done and (2) shifting more of if not the entire cost onto the patient. Having said that, I do not see how a practice can be profitable seeing patients out-of-network if they are not collecting the vast majority of the charges from patients.

 

[Nonphysiologic]

Agreed, this doesn't make ANY sense to me. From what I understand people with good insurances with out of network benefits will pay for "premier" doctors so a lot of this kind of model makes sense in wealthy areas but I don't understand why an insurance company wouldn't just give you their rate if youre out of network.

 

[jsaul]

Where I am the out of network game works like this.

Basically a patient does not realize the doctor is out of network and agrees to services to the out of network doctor during a high pressure situation

. Usually it's the anesthesia group at the in network surgery center and where the in network surgeon is doing the case. The anesthesia group is out of network and Basically the patient has no choice in the matter as the anesthssia group presents to the patiant an agreement to treat form right as the patient is checking in for surgery. the patient does not realize what they are signing at such a time. they then get the big surprise a few weeks after their surgery of a huge bill from anesthesia

the game works the same way in the ER with plastics and ortho. A patient goes to an in network hospital ER with some kind of trauma and assumes the doctors are in network too. THey come in with some trauma the ER calls ortho, The ortho doctor comes in and does whatever and then the patient gets a huge bill a few weeks later from the ortho

It is hard for a pain practice to be out of network because the patient will usually know before hand you are OON and would seek care elsewhere to avoid the OON scare.

 

[Pain Applicant1]

Where I am the out of network game works like this.

Basically a patient does not realize the doctor is out of network and agrees to services to the out of network doctor during a high pressure situation

. Usually it's the anesthesia group at the in network surgery center and where the in ketwrok surgeon is doing the case. The anesthesia group is out of network and Basically the patient has no choice in the matter as the anesthssia group presents to the patiant a agreement to treat form right as the patient is checking in for surgery. the patient does not realize what they are signing at such a time. the then get the big surprise a few weeks after their surgery of a huge bill from anesthesia

the game works the same way in the ER with plastics and ortho. A patient goes to an in network hospital ER with some kind of trauma and assumes the doctors are in network too. THey come in with some trauma the ER calls ortho, The ortho doctor comes in and does whatever and then the patient gets a huge bill a few weeks later from the ortho

It is hard to a pain practice out of network because the patient will usually know before hand you are OON and would seek care elsewhere.

Let's not forget about the last part. Most pts can't afford the bill so the hospital or medical group then puts a lien on the patient's house. This is one reason why most bankruptcies in the US are due to medical bills.

Most American doctors are already well into the 1%. Most American non-doctors are living paycheck to paycheck. Let's all help each other out and figure out a way that we can each collect $4000 for an epidural injection. This will help make this situation even more sustainable than it already is. After all, an LESI does take about 6 minutes to do.

 

[GeneralLancer]

I have my own practice and I know how to make a practice very profitable. I can walk you through the process step by step but I would not sleep well at night if I gave you any advice as I would never support someone who gave the example that you gave.

Not to judge too harshly but anyone who is bringing in $4000 for an epidural should probably be jailed.

@Pain Applicant1 I've DM'ed you. Looking forward to what insight you have to share.

 

[Pain Applicant1]

@Pain Applicant1 I've DM'ed you. Looking forward to what insight you have to share.

I'm happy to answer questions in the public forum but ask direct, targeted questions. It's difficult to answer broad-based questions.

 

[Laryngospasm]

This is often called “surprise billing” , Biden has a plan to make this illegal last time I heard. So you folk who are counting on this as a way to make money might be living on borrowed time. But then again I think we all might be.

 

[GeneralLancer]

I know how to make a practice very profitable. I can walk you through the process step by step

I'm happy to answer questions in the public forum but ask direct, targeted questions. It's difficult to answer broad-based questions.

@Pain Applicant1 , thanks

1. You mentioned 'how to make a practice very profitable' and that you can 'walk through the process step by step'. Could you please elaborate - is it patient selection, increasing efficiency, decreasing A/R, negotiating higher reimbursement with payors, adding in-office-ancillary services etc? I tried to make it as specific as possible.

2. How do you approach a market analysis in terms of selecting a location for clinic and ASC? I image you look at demographics, large employers, local physicians.

3. Do you do your billing in-house or outsource it? Would you recommend any companies?

4. What mistakes do you see new graduates make when evaluating an offer?

5. Having a good bedside manner is essential. What tips and tricks do you have (ie hand on the shoulder, repeating pts first name, smiling, etc)?

6. What are your thoughts about 2-3 exam rooms in a clinic along with 2 ASC rooms under one facility?

7. There are numerous ways to analyze the purchase of shares into an ASC. Which ones do you recommend?

8. Getting referrals is key. What do you like to tell the FM, chiros, podiatrists, surgeons etc to make them want to give you patients who would benefit from an intervention?

9. What are red flags when analyzing a smaller practice (ie no one has a DEA license, you only see med refills, etc)?

10. What in-office ancillary services would you recommend (dispensing, MRI, DME, PT)?

11. What are the keys to being morally and financially sound when dealing with WC and PI?

Thank you.

 

[Pain Applicant1]

@Pain Applicant1 , thanks

1. You mentioned 'how to make a practice very profitable' and that you can 'walk through the process step by step'. Could you please elaborate - is it patient selection, increasing efficiency, decreasing A/R, negotiating higher reimbursement with payors, adding in-office-ancillary services etc? I tried to make it as specific as possible.

Be kind to patients and do a good job. Keep overhead low. It's really that simple. Buy low sell high sort of thing. I pretty much have zero leverage when negotiating with insurances or at least that's what I believe. Either way, I have little motivation at this time to make my practice more profitable so I wouldn't waste my time negotiating with payers at this point. I assume you're younger than me so you're probably a bit more eager than I am. Like everything in business, ancillaries are just a numbers game. Do the calculation to determine its profitability prior to making the investment. Don't forget to include your time in that calculation.

2. How do you approach a market analysis in terms of selecting a location for clinic and ASC? I image you look at demographics, large employers, local physicians.

I didn't buy into the ASC. I did a demographic analysis using wikipedia for population numbers and google maps to identify referring doctors and my competitors. I called my competitors to find out how booked out they were prior to opening up. I called the local hospital and was able to convince them to fund the entirety of my start-up costs plus guarantee me a handsome salary. It's called income guarantee and loan forgiveness. You might want to look into this.

3. Do you do your billing in-house or outsource it? Would you recommend any companies?

This is the most important question you've asked so far and it was my biggest mistake. I estimate it cost me hundreds of thousands of dollars in the early phases. You must know billing back and forth and I recommend for you to do it yourself until you have it down like clockwork. All billing companies are terrible, PERIOD. I use a hybrid system with billing through Athena.

4. What mistakes do you see new graduates make when evaluating an offer?

Can't answer this since I've never worked for anyone. I started my own practice immediately after fellowship.

5. Having a good bedside manner is essential. What tips and tricks do you have (ie hand on the shoulder, repeating pts first name, smiling, etc)?

You either have it or you don't. You can't learn this stuff and if you have to try it will come off as fake. I trained at Harvard and was never really that comfortable there. Not my cup of tea. Fortunately, I love where I live now, feel like I fit in well, and I have a very strong sense of community. I recommend you live and work in a community you mesh well in. Our country is so big and there are so many subcultures you're sure to find one you like. Over the years, I lived throughout much of the US and as you likely already know, there's a big difference between a small rural southern town and NYC.

I feel like my bedside manner is my strongest quality and my pts seem to like me. Then again, I guess I could be wrong.

6. What are your thoughts about 2-3 exam rooms in a clinic along with 2 ASC rooms under one facility?

I use 2-3 rooms plus my fluoro suite. Never bought into the ASC.

7. There are numerous ways to analyze the purchase of shares into an ASC. Which ones do you recommend?

I was offered a buy-in option. I calculated my return and felt it would be better to keep my procedures in my office. This is also more affordable to patients. I treasure my autonomy so the more control I have over my operation the better. This fits my personality and is not for everyone.

8. Getting referrals is key. What do you like to tell the FM, chiros, podiatrists, surgeons etc to make them want to give you patients who would benefit from an intervention?

See #5

9. What are red flags when analyzing a smaller practice (ie no one has a DEA license, you only see med refills, etc)?

I never worked for anyone else since I graduated fellowship so I can't answer this. The best thing about having your own practice, at least for me, is freedom and independence. I turn patients down all the time and never push pts into procedures as I have no pressure from above to do so. I do what I feel is right when I feel it's right.

I don't like the idea of someone else profiting from my labor. The money is good too but for me, it comes secondary to my autonomy.

10. What in-office ancillary services would you recommend (dispensing, MRI, DME, PT)?

I do DME and UDS. I imagine an MRI would be an expensive endeavor but have at it if the numbers work out. You can look into PT and dispensing but I'm probably not the best person to ask about ancillaries at this point. As mentioned above, I have little interest in generating more revenue for my practice. Right now, I'm focusing on my other businesses.

11. What are the keys to being morally and financially sound when dealing with WC and PI?

I treat these pts as I treat all of my pts. I could care less about their insurance policies and rarely look at who the payor is.

Thank you.

 

[MetaPhysicianBlog]

Be kind to patients and do a good job. Keep overhead low. It's really that simple. Buy low sell high sort of thing. I pretty much have zero leverage when negotiating with insurances or at least that's what I believe. Either way, I have little motivation at this time to make my practice more profitable so I wouldn't waste my time negotiating with payers at this point. I assume you're younger than me so you're probably a bit more eager than I am. Like everything in business, ancillaries are just a numbers game. Do the calculation to determine its profitability prior to making the investment. Don't forget to include your time in that calculation.

I didn't buy into the ASC. I did a demographic analysis using wikipedia for population numbers and google maps to identify referring doctors and my competitors. I called my competitors to find out how booked out they were prior to opening up. I called the local hospital and was able to convince them to fund the entirety of my start-up costs plus guarantee me a handsome salary. It's called income guarantee and loan forgiveness. You might want to look into this.

This is the most important question you've asked so far and it was my biggest mistake. I estimate it cost me hundreds of thousands of dollars in the early phases. You must know billing back and forth and I recommend for you to do it yourself until you have it down like clockwork. All billing companies are terrible, PERIOD. I use a hybrid system with billing through Athena.

Can't answer this since I've never worked for anyone. I started my own practice immediately after fellowship.

You either have it or you don't. You can't learn this stuff and if you have to try it will come off as fake. I trained at Harvard and was never really that comfortable there. Not my cup of tea. Fortunately, I love where I live now, feel like I fit in well, and I have a very strong sense of community. I recommend you live and work in a community you mesh well in. Our country is so big and there are so many subcultures you're sure to find one you like. Over the years, I lived throughout much of the US and as you likely already know, there's a big difference between a small rural southern town and NYC.

I feel like my bedside manner is my strongest quality and my pts seem to like me. Then again, I guess I could be wrong.

I use 2-3 rooms plus my fluoro suite. Never bought into the ASC.

I was offered a buy-in option. I calculated my return and felt it would be better to keep my procedures in my office. This is also more affordable to patients. I treasure my autonomy so the more control I have over my operation the better. This fits my personality and is not for everyone.

See #5

I never worked for anyone else since I graduated fellowship so I can't answer this. The best thing about having your own practice, at least for me, is freedom and independence. I turn patients down all the time and never push pts into procedures as I have no pressure from above to do so. I do what I feel is right when I feel it's right.

I don't like the idea of someone else profiting from my labor. The money is good too but for me, it comes secondary to my autonomy.

I do DME and UDS. I imagine an MRI would be an expensive endeavor but have at it if the numbers work out. You can look into PT and dispensing but I'm probably not the best person to ask about ancillaries at this point. As mentioned above, I have little interest in generating more revenue for my practice. Right now, I'm focusing on my other businesses.

I treat these pts as I treat all of my pts. I could care less about their insurance policies and rarely look at who the payor is.

Thanks again for taking the time to answer all my questions thoughtfully. I appreciate your kindness.

a) How many square foot is your set up? What would you recommend?

b) What is the workflow for your set up (ie intake is by MA#1, rooming by MA#1 while you are with patient, etc)?

c) How many MAs/PAs/NPs/back end/front end people do you employ?
cc) When did you decide to bring those people on board (ie once new patients > X, once revenue was above Y, etc)

d) So 2-3 clinic rooms and 1 fluoro suite, correct? Do you rent or own your space?

e) What is your time breakdown roughly for clinic time versus fluoro procedures?

g) Sounds like you had a sweet deal with the local hospital for start ups. That is slick. What did you say to 'convince' them to do this? What metrics did you bring up to have them view you in a favorable light?

f) Since you understand business metrics well what is your profit per year for DME and UDS, roughly speaking?

g) When you were fresh out of fellowship starting your own practice what did you say to convince referring physicians to send you patients? I assume there were other more experienced pain physicians, knew the lay of the land, etc.

Again thank you for your time

 

[Pain Applicant1]

Thanks again for taking the time to answer all my questions thoughtfully. I appreciate your kindness.

a) How many square foot is your set up? What would you recommend?

I own the entire building I'm in. It's 8,000 square feet. I cut out about 2300 sq feet for my practice. The rest of the building I rented out to other tenants. I use well under this amount in my office. I would estimate about half. The parts of my office I don't use I also rent out to tenants. I have one therapist in the back, a disability company, and a cardiologists who rents part-time from me on Fri and Sat when I'm not there.

b) What is the workflow for your set up (ie intake is by MA#1, rooming by MA#1 while you are with patient, etc)?

I have only one employee at this time. I used to have 3 but have whittled it down. I hate being a boss and hate telling other people what to do, mainly because I don't like being told what to do. So, I worked hard to figure out ways to have as few employees as possible. I've made it work. The only issue is that patients go into voicemail when she's not at the front desk. Most are understanding.

c) How many MAs/PAs/NPs/back end/front end people do you employ?
cc) When did you decide to bring those people on board (ie once new patients > X, once revenue was above Y, etc)

1 employee. I see over 100 pts a week and I work 4 days. No PAs or NPs. I thought about hiring one and it would be a good move financially but I would then have to manage this person. I like being hands-on with my pts and I feel responsible for them so I wouldn't trust my pts with someone else. My personality trait of wanting to do everything myself and of not wanting to be a boss is NOT good for business. I am NOT a good business person. It hinders me financially and my practice would be far more expansive and lucrative if I opened myself up more. Unfortunately for me, it's not worth the trade-off. I do not need or want any more money from my practice and am happy where I am. I DO NOT recommend you follow my lead with this.

d) So 2-3 clinic rooms and 1 fluoro suite, correct? Do you rent or own your space?

Own as noted above. I like my pts but my heart is really in construction and real estate. I take far more pride in the things I build with my hands than whatever I accomplished with my education. I have diplomas from hopkins and harvard and both are sitting at the bottom of a desk somewhere. I am grateful and appreciative of these institutions and what they and my education have provided for me and my family but I tend to be more boastful about my farm fence I'm just about finishing up. I built over 7000 linear feet of fencing on my own. I even felled my own trees with a chainsaw to make the posts. See what I mean. Do what you love.

e) What is your time breakdown roughly for clinic time versus fluoro procedures?

30 min new pts, 10 min follow ups, 30 min procedures. Most procedures, minus stim and kypho, are done within 5 to 15 minutes. Most news pts are done with 15 to 20 min and follow ups within 5 minutes. I can reduce the scheduled time more but you really have to work up to that. You have to develop the stamina and rhythm for both you and your staff to increase the flow of pts to handle this many. I would recommend that you never make the pt feel rushed.

g) Sounds like you had a sweet deal with the local hospital for start ups. That is slick. What did you say to 'convince' them to do this? What metrics did you bring up to have them view you in a favorable light?

I gave a presentation to the CFO, CEO, and some others. I told them how I would benefit the community so on and so forth. However, the real thing they were concerned of course was the bottom line so I told them that pain pts require procedures, PT, MRIs, ortho referral yada yada yada. I also used their surgical center for the first few months.

f) Since you understand business metrics well what is your profit per year for DME and UDS, roughly speaking?

With COVID, I don't dispense much DME anymore. The profit here is not that high for me and I mainly started the UDS to help monitor my suboxone pts. I really like doing suboxone, sometimes more than pain. The profit margins are high since both DME and UDS are not that costly, respectively. You can generate a lot of profit if that is something you are interested in. Plenty of people do.

g) When you were fresh out of fellowship starting your own practice what did you say to convince referring physicians to send you patients? I assume there were other more experienced pain physicians, knew the lay of the land, etc.

IMO, you can't convince them. To me, NP/DO/MD/PA/MBBS/Foreign Grad/Chiro/Harvard/Caribbean etc whatever else I'm missing means very little outside of academic circles. It doesn't matter where you trained and how great you think you are or how arrogant of a physician you may or may not be. When you hear people tossing it around, it's only because they want to promote themselves for their own benefit so they need to denigrate others to protect their piece of the pie. The best analogy is the airplane pilot. When you enter an airplane, you don't really think about where the pilot did his or her training. You are just confident that this person is trained well. That's how the pts see us.

The only thing, the ABSOLUTE only thing that matters, is if pts like you. This is more important than doing a good job and having good outcomes but they usually go hand in hand. If the pts like you, they will refer others to you. If the pts like you, it gets back to the referring docs and you will get more referrals. You are a reflection of the referring doctor so if you treat a pt poorly it makes the referrer look bad. The converse is also true. If the pt likes you and has confidence in you, you will have good outcomes. This is more important than needle placement and procedure technique. I think there's a study somewhere out there that supports this.

Again thank you for your time

 

[Pain Applicant1]

To me, NP/DO/MD/PA/MBBS/Foreign Grad/Chiro/Harvard/Caribbean etc whatever else I'm missing means very little outside of academic circles.

Here are few more mumbojumbo words to add the list ANESTHES/PMR/NEURO/ER/PSYCH/ACGME/NONACGME

 

[Nonphysiologic]

I own the entire building I'm in. It's 8,000 square feet. I cut out about 2300 sq feet for my practice. The rest of the building I rented out to other tenants. I use well under this amount in my office. I would estimate about half. The parts of my office I don't use I also rent out to tenants. I have one therapist in the back, a disability company, and a cardiologists who rents part-time from me on Fri and Sat when I'm not there.

I have only one employee at this time. I used to have 3 but have whittled it down. I hate being a boss and hate telling other people what to do, mainly because I don't like being told what to do. So, I worked hard to figure out ways to have as few employees as possible. I've made it work. The only issue is that patients go into voicemail when she's not at the front desk. Most are understanding.

1 employee. I see over 100 pts a week and I work 4 days. No PAs or NPs. I thought about hiring one and it would be a good move financially but I would then have to manage this person. I like being hands-on with my pts and I feel responsible for them so I wouldn't trust my pts with someone else. My personality trait of wanting to do everything myself and of not wanting to be a boss is NOT good for business. I am NOT a good business person. It hinders me financially and my practice would be far more expansive and lucrative if I opened myself up more. Unfortunately for me, it's not worth the trade-off. I do not need or want any more money from my practice and am happy where I am. I DO NOT recommend you follow my lead with this.

Own as noted above. I like my pts but my heart is really in construction and real estate. I take far more pride in the things I build with my hands than whatever I accomplished with my education. I have diplomas from hopkins and harvard and both are sitting at the bottom of a desk somewhere. I am grateful and appreciative of these institutions and what they and my education have provided for me and my family but I tend to be more boastful about my farm fence I'm just about finishing up. I built over 7000 linear feet of fencing on my own. I even felled my own trees with a chainsaw to make the posts. See what I mean. Do what you love.

30 min new pts, 10 min follow ups, 30 min procedures. Most procedures, minus stim and kypho, are done within 5 to 15 minutes. Most news pts are done with 15 to 20 min and follow ups within 5 minutes. I can reduce the scheduled time more but you really have to work up to that. You have to develop the stamina and rhythm for both you and your staff to increase the flow of pts to handle this many. I would recommend that you never make the pt feel rushed.

I gave a presentation to the CFO, CEO, and some others. I told them how I would benefit the community so on and so forth. However, the real thing they were concerned of course was the bottom line so I told them that pain pts require procedures, PT, MRIs, ortho referral yada yada yada. I also used their surgical center for the first few months.

With COVID, I don't dispense much DME anymore. The profit here is not that high for me and I mainly started the UDS to help monitor my suboxone pts. I really like doing suboxone, sometimes more than pain. The profit margins are high since both DME and UDS are not that costly, respectively. You can generate a lot of profit if that is something you are interested in. Plenty of people do.

IMO, you can't convince them. To me, NP/DO/MD/PA/MBBS/Foreign Grad/Chiro/Harvard/Caribbean etc whatever else I'm missing means very little outside of academic circles. It doesn't matter where you trained and how great you think you are or how arrogant of a physician you may or may not be. When you hear people tossing it around, it's only because they want to promote themselves for their own benefit so they need to denigrate others to protect their piece of the pie. The best analogy is the airplane pilot. When you enter an airplane, you don't really think about where the pilot did his or her training. You are just confident that this person is trained well. That's how the pts see us.

The only thing, the ABSOLUTE only thing that matters, is if pts like you. This is more important than doing a good job and having good outcomes but they usually go hand in hand. If the pts like you, they will refer others to you. If the pts like you, it gets back to the referring docs and you will get more referrals. You are a reflection of the referring doctor so if you treat a pt poorly it makes the referrer look bad. The converse is also true. If the pt likes you and has confidence in you, you will have good outcomes. This is more important than needle placement and procedure technique. I think there's a study somewhere out there that supports this.

 

[Nonphysiologic]

Hey this is really interesting. So you convinced the hospital to help start your practice? Were they trying to get you to do inpatient as well?

This is an interesting concept. I wonder how I would even get in touch with any decision makers or make a convincing argument back by data?

 

[Pain Applicant1]

Hey this is really interesting. So you convinced the hospital to help start your practice? Were they trying to get you to do inpatient as well?

This is an interesting concept. I wonder how I would even get in touch with any decision makers or make a convincing argument back by data?

They don't care about inpt but you do need privileges for the payers. I just cold-called a few hospitals after I located my target area from my demographic analysis. I spoke to the physician recruiter who passed my information up the line.

 

[Ligament]

How can do you see so many patients and do procedures with one employee?
Example; doing a L3-5 mb RFA. Assuming following ISIS technique of parallel active tip placement, going to take you minimum of 30 mins of MA/C-arm operator time (rooming, prepping, imaging), minimum of 20 mins your hands on time doing procedure. Both you and your employee are tied up in the procedure room the entire time. Who is checking in and rooming the patients arriving? Who is rooming the next patient? Who is checking ID cards and insurance cards and verifying benefits? Who is monitoring the office (are patients freely roaming unsupervised?). Who is taking copays? Who is answering the phone? All these things need to be happening while you and your one employee are tied up in the procedure room.

Your waiting room is unstaffed with patients waiting and arriving. How do you handle that?

I'm all for reducing overhead (I am overstaffed, no doubt) but trying to wrap my brain around how you can do 100 pts/week including stims/kyphos with one staff member. If you loose one staff member, you have nobody...your business is shut down until you find and train another staff member.

 

[Ducttape]

no offense, but this is not the type of practice that I could be involved in.

5 minutes is not enough time for me to greet and bond with my follow up patients. 15 min for a new patient would be rushed for me regardless of how I sugar coat it. it takes me 5 minutes just to do the physical exam...

(tho my run of mill procedure times are only 20 min)

 

[Pain Applicant1]

How can do you see so many patients and do procedures with one employee?
Example; doing a L3-5 mb RFA. Assuming following ISIS technique of parallel active tip placement, going to take you minimum of 30 mins of MA/C-arm operator time (rooming, prepping, imaging), minimum of 20 mins your hands on time doing procedure. Both you and your employee are tied up in the procedure room the entire time. Who is checking in and rooming the patients arriving? Who is rooming the next patient? Who is checking ID cards and insurance cards and verifying benefits? Who is monitoring the office (are patients freely roaming unsupervised?). Who is taking copays? Who is answering the phone? All these things need to be happening while you and your one employee are tied up in the procedure room.

Your waiting room is unstaffed with patients waiting and arriving. How do you handle that?

I'm all for reducing overhead (I am overstaffed, no doubt) but trying to wrap my brain around how you can do 100 pts/week including stims/kyphos with one staff member. If you loose one staff member, you have nobody...your business is shut down until you find and train another staff member.

RFL takes me a bit longer than 15 min but usually less than 30 min. I do bilateral LMBB but only unilateral RFL. My front desk girl is setting the pt up in the fluoro suite while I'm seeing pts. She gets me when the pt is on the table. I prep and draw up meds as I feel better if I do these. We are both in the fluoro suite at the same time. Procedure is done I walk the pt to the post procedure suite and head out to the next pt. Most procedures are done well within the 30 min allotment so we can get caught up if we fall behind. We keep the front door locked due to COVID so we limit traffic so no one comes into the office without anyone at the front. The only pts who come in for appts are new pts, procedures, and any f/u's who need to be re-evaluated. We try to maximize telemed appts due to COVID and for pt convenience. We schedule telemed appts after in office visits so the front desk doesn't need to check a pt in following an in office pt. This way we have only one pt in the office at a time. By the time the procedure pt is out of the office and the next pt is ready to come in the front desk girl has returned to the front and the cycle starts over. No family is allowed unless absolutely necessary due to COVID. I no longer allow the pts in the waiting room. They must wait in their cars if necessary. The waiting room is for my employee's kid when he's not in school due to COVID restrictions.

I run eligibility through Athena with the click of a button. Copays are now collected after I see the pt, not before. Anyone with a major balance gets put on a payment plan to get caught up. If they don't or can't pay, I still see them regardless but I try to collect what I can. I don't discharge due to lack of payment. The phone seems to be the only issue as it does go into voicemail often. I hate voicemail but fortunately, most pts are understanding.

Kyphos and stims are scheduled for the end of the day so I don't have to feel rushed. I can take longer if necessary.

I do have all my eggs in one basket with one employee. Is it worth the risk? I pay about $18/hr about 35 hrs per week. I guess that's around $35000 per year give or take. That's 100k in 3 yrs, it adds up. Is it worth the risk to pay that for another employee? I guess it depends on how comfortable you are with risk. If she's sick or out it'll be an issue. Fortunately, I have kept good relations with my former employees. They are all crossed trained in operating the fluoro, the EHR, and admin etc. I'm hoping I can depend on them if a serious issue occurs. Worst case scenario is I would just have to cancel all procedures until I can get an employee back in. I can do most of the office visit stuff myself minus the fluoro if necessary. I had to cancel procedures before when my fluoro crashed. I survived that so I could survive again if necessary.

 

[Pain Applicant1]

no offense, but this is not the type of practice that I could be involved in.

5 minutes is not enough time for me to greet and bond with my follow up patients. 15 min for a new patient would be rushed for me regardless of how I sugar coat it. it takes me 5 minutes just to do the physical exam...

(tho my run of mill procedure times are only 20 min)

No offense taken and it may not be for you. I can 100% assure you I have solid relationships with all of my pts. My pts buy and make me stuff all the time, including the fresh tomato juice from my pt's garden pictured below, and I've become friends with many of them. You can say it's crossing the line but in my small town, it's hard not to. I see someone I know almost every time I go out and I interact with my pts in my other businesses. We work construction jobs together, we do heavy equipment maintenance on my farm/construction equipment together, we do real estate deals together, we farm together, they hunt my land, etc. I've learned a lot from my pts. I had no idea how to rebuild a cylinder on a track loader until I came here. I'm really tied into this community and it's impossible to avoid interactions outside of the office. I turn many pts down and my office is self-filtering. Those who don't like me won't come back so it filters for the pts who I get along with. Many pts have called me on their death beds to say good bye and to thank me. Many family members have called me after the pt dies to thank me. These things must mean I'm doing something right.

 

[claner1]

No offense taken and it may not be for you. I can 100% assure you I have solid relationships with all of my pts. My pts buy and make me stuff all the time, including the fresh tomato juice from my pt's garden pictured below, and I've become friends with many of them. You can say it's crossing the line but in my small town, it's hard not to. I see someone I know almost every time I go out and I interact with my pts in my other businesses. We work construction jobs together, we do heavy equipment maintenance on my farm/construction equipment together, we do real estate deals together, we farm together, they hunt my land, etc. I've learned a lot from my pts. I had no idea how to rebuild a cylinder on a track loader until I came here. I'm really tied into this community and it's impossible to avoid interactions outside of the office. I turn many pts down and my office is self-filtering. Those who don't like me won't come back so it filters for the pts who I get along with. Many pts have called me on their death beds to say good bye and to thank me. Many family members have called me after the pt dies to thank me. These things must mean I'm doing something right.

@Pain Applicant1 I’m a PGY-2 PM&R resident planning to go into pain. I’ve been following your posts and have been struck by your entrepreneurial mindset with starting up your own practice straight out of fellowship as well as your mentions of real estate investing. I’m at a large academic center in the Midwest and realizing that academics breeds academicians. I came into residency wanting to return to the Dallas/Fort Worth area where I’m originally from and to be a community pain doctor, because I value my autonomy and don’t ever want to be an employee. Some questions I had were:

1) Given your experience with private practice pain and it’s evolution, how feasible do you think it is in this current healthcare landscape to start my own practice once I graduate in 2024? I’ve heard the DFW area is becoming more saturated but I’m not opposed to looking into the surrounding areas that are more rural and less saturated. Another thing to note is I have a wife and two kids — I know starting a practice is a huge endeavor compared to being an employee and I want to make sure I’m not being idealistic with being able to balance work and my commitment to my family. I’m more than willing to hustle but what would you advise to someone with a family?

2) If you were in my shoes, what would you start learning and doing during residency to help better set yourself up for success in running a private practice? Anything you would have done differently or sooner knowing what you do now?

3) What are your thoughts on financial freedom and doing this through real estate? I’ve read Rich Dad Poor Dad, listened to WCI and Passive Income MD, and getting into BiggerPockets at the moment. All of this is making me think that medicine will not help me build wealth given I have to consistently trade my time for money. Therefore I’ve been considering getting into real estate investing even now in residency to help build a passive income steam. We house hack and have an investment property in Fort Worth. Any thoughts on BRRRR, rentals, syndications, REITs? What kind of real estate investing do you do?

Thanks in advance for answering this newbie's questions!

 

[Pain Applicant1]

@Pain Applicant1 I’m a PGY-2 PM&R resident planning to go into pain. I’ve been following your posts and have been struck by your entrepreneurial mindset with starting up your own practice straight out of fellowship as well as your mentions of real estate investing. I’m at a large academic center in the Midwest and realizing that academics breeds academicians. I came into residency wanting to return to the Dallas/Fort Worth area where I’m originally from and to be a community pain doctor, because I value my autonomy and don’t ever want to be an employee. Some questions I had were:

1) Given your experience with private practice pain and it’s evolution, how feasible do you think it is in this current healthcare landscape to start my own practice once I graduate in 2024? I’ve heard the DFW area is becoming more saturated but I’m not opposed to looking into the surrounding areas that are more rural and less saturated. Another thing to note is I have a wife and two kids — I know starting a practice is a huge endeavor compared to being an employee and I want to make sure I’m not being idealistic with being able to balance work and my commitment to my family. I’m more than willing to hustle but what would you advise to someone with a family?

I'm not familiar with the current landscape since I haven't been evaluating it. I do know that there is always opportunity and I likely would still start my own practice regardless of when I graduated fship.

I'm married with kids too and my family always comes first. When I first started, I was working until midnight many nights. I didn't have kids at that time so that's something you'll have to consider. I'm glad I had a 24 hour Walmart when I started as there is always business-related items that come up.

I definitely put the time in but I had invested and made enough where I could've retired by the time I was 40 despite starting medical school a few years after college as I worked and traveled before. I took the money from my practice and poured it into real estate as I considered it the perfect once in a lifetime opportunity. Money was and is cheap and the real estate market was depressed. I knew it wouldn't last forever.

2) If you were in my shoes, what would you start learning and doing during residency to help better set yourself up for success in running a private practice? Anything you would have done differently or sooner knowing what you do now?

Befriend the billers. You'll learn the medical part once you start practicing. I should have done my own biilling beginning straight from the opening.

3) What are your thoughts on financial freedom and doing this through real estate? I’ve read Rich Dad Poor Dad, listened to WCI and Passive Income MD, and getting into BiggerPockets at the moment. All of this is making me think that medicine will not help me build wealth given I have to consistently trade my time for money. Therefore I’ve been considering getting into real estate investing even now in residency to help build a passive income steam. We house hack and have an investment property in Fort Worth. Any thoughts on BRRRR, rentals, syndications, REITs? What kind of real estate investing do you do?

Thanks in advance for answering this newbie's questions!

I like Rich Dad Poor Dad, although 90% is fluff the concept is important. You can easily become rich from medicine but you are still an employee. With that said, there is no such thing as a truly passive income. There is always responsibility and things that need managing. Decisions need to be made and problems must be addressed. There is always risk.

I own a lot of land, commercial, and residential real estate. I would never buy in this market. I like to buy when others don't. True to this concept, the COVID stock market crash back in March or April has been very good to me but I think it will likely be time to sell very soon as everyone is starting to buy. With real estate, I predict the next major correction around 2027. That will be my cue to jump back in.

 

[Pain Applicant1]

@Pain Applicant1 I’m a PGY-2 PM&R resident planning to go into pain. I’ve been following your posts and have been struck by your entrepreneurial mindset with starting up your own practice straight out of fellowship as well as your mentions of real estate investing. I’m at a large academic center in the Midwest and realizing that academics breeds academicians. I came into residency wanting to return to the Dallas/Fort Worth area where I’m originally from and to be a community pain doctor, because I value my autonomy and don’t ever want to be an employee. Some questions I had were:

1) Given your experience with private practice pain and it’s evolution, how feasible do you think it is in this current healthcare landscape to start my own practice once I graduate in 2024? I’ve heard the DFW area is becoming more saturated but I’m not opposed to looking into the surrounding areas that are more rural and less saturated. Another thing to note is I have a wife and two kids — I know starting a practice is a huge endeavor compared to being an employee and I want to make sure I’m not being idealistic with being able to balance work and my commitment to my family. I’m more than willing to hustle but what would you advise to someone with a family?

2) If you were in my shoes, what would you start learning and doing during residency to help better set yourself up for success in running a private practice? Anything you would have done differently or sooner knowing what you do now?

3) What are your thoughts on financial freedom and doing this through real estate? I’ve read Rich Dad Poor Dad, listened to WCI and Passive Income MD, and getting into BiggerPockets at the moment. All of this is making me think that medicine will not help me build wealth given I have to consistently trade my time for money. Therefore I’ve been considering getting into real estate investing even now in residency to help build a passive income steam. We house hack and have an investment property in Fort Worth. Any thoughts on BRRRR, rentals, syndications, REITs? What kind of real estate investing do you do?

Thanks in advance for answering this newbie's questions!

Oh, with land I subdivide and will develop it. Commercial i rent out to tenants. Residential I fix up and rent out. I know construction so this is helpful. If you don't know how to use a saw, you might want to be careful with real estate.

 

[PikminOC]

Yes real estate is passive income. Can't work like a dog forever in medicine