Question about timing of license/insurance credentialing and office vs ASC based procedures.

BW15

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Hi everyone,

I had a few questions that I'd like to get some advice on.

I will start my fellowship in July. I will then be moving to another state after my fellowship. I've been told that it takes about 6 months to get your license in this state.

1. I don't want to apply too early for the license because then I won't be using it until I move there (and will have to reapply for renewal sooner). But on the other hand if I get my license early I can start applying for insurance credentialing with a PO box address while I'm still a fellow so that I have everything lined up by the time I move. What would you guys do? Apply now or later (in October)?

2. My goal has always been to open my own practice, but the location I'll be moving to is somewhat saturated from what I've been told. My plan was to do anesthesiology full/part time while saving money to open my own practice. Then phase out anesthesiology as I get busier with my practice. I was also thinking about hiring a consulting company to help me with it. Any advice on this? Does this sound like a good plan? Another option would be to find a pain management job, but I can't find many in the region and they tend to pay less than anesthesiology jobs for new graduates.

3. I've been searching for information about single specialty ASC requirements, but cant really find much information. Is it worth spending the money to do the bare minimum to be considered a single specialty ASC for your procedures to collect facility fees vs just doing them in your office without the ASC designation? I've read single specialty ASC can cost around 500-700k (not including land), but what do you think it would cost to just do the bare minimum to have your office considered an ASC for reimbursement purposes?

Thanks, I appreciate any advice.
 

gdub25

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1. Apply now, you can’t see patients if you’re not credentialed, can get credentialed without state license. You’re going to have to renew your license either way, what difference does it make if you’re up for renewal a few months earlier than you would be otherwise.

2. Starting your own practice is hard, however the best way to do it is like you’ve mentioned. Anesthesia part time or overnight shifts and then doing pain when you can carve out time is a safe way to do it while still bringing in steady income. Will take tome to get busy but if you’re patient it will work and doing anesthesia will give you great opportunities to build relationships with surgeons.

3. I love your ambition, thinking about ASC construction before fellowship, but there is a lot of road to cover before you’re ready to conquer this feat. I don’t want to discourage you at all, I’m an ambitious dreamer myself, it’s just that you have to build up a successful practice before it makes any business sense to build an ASC. Sure, reimbursement is higher in the ASC but so is overhead and you’ll need a certain threshold of injection volume before the ASC makes sense. Your cost estimates are way off for building an ASC as well. Single OR, single specialty ASC in Texas, built in 2016 was 2.1 million. In Oklahoma for a 2 OR single specialty, 4.5 million. Both are not including land which is typically $8-13 per square foot and with a lot big enough to build an ASC on, even single OR, you’ll need an acre to meet code for building size and parking so figure $300k and up for land.
 
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BW15

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Apr 7, 2015
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Thanks for the advice, I really appreciate it! I'll apply for the state license now and just work on building my practice slowly once I'm done.
 

hyperalgesia

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Hi everyone,

I had a few questions that I'd like to get some advice on.

I will start my fellowship in July. I will then be moving to another state after my fellowship. I've been told that it takes about 6 months to get your license in this state.

1. I don't want to apply too early for the license because then I won't be using it until I move there (and will have to reapply for renewal sooner). But on the other hand if I get my license early I can start applying for insurance credentialing with a PO box address while I'm still a fellow so that I have everything lined up by the time I move. What would you guys do? Apply now or later (in October)?

2. My goal has always been to open my own practice, but the location I'll be moving to is somewhat saturated from what I've been told. My plan was to do anesthesiology full/part time while saving money to open my own practice. Then phase out anesthesiology as I get busier with my practice. I was also thinking about hiring a consulting company to help me with it. Any advice on this? Does this sound like a good plan? Another option would be to find a pain management job, but I can't find many in the region and they tend to pay less than anesthesiology jobs for new graduates.

3. I've been searching for information about single specialty ASC requirements, but cant really find much information. Is it worth spending the money to do the bare minimum to be considered a single specialty ASC for your procedures to collect facility fees vs just doing them in your office without the ASC designation? I've read single specialty ASC can cost around 500-700k (not including land), but what do you think it would cost to just do the bare minimum to have your office considered an ASC for reimbursement purposes?

Thanks, I appreciate any advice.
1. Agree with get the license now. You might need a state-based narcotic license too. You could get credentialed in your primary specialty with both hospitals and insurance companies. Getting on insurance panels is a huge and underappreciated challenge in some areas.

2. I wouldn't do the consulting company. If your dream is to set up your own pain, the anesthesia plan sounds perfect. If you get a pain job, obviously be extremely careful about what you sign, re: non-compete clause in the contract.

3. gdub25 put it perfectly about the ASC. I'll just add that every state has different rules. Your state might require political schmoozing to get a "certificate of need" that must be endorsed by a local hospital. It could be an absolute impossibility or it might be a lot cheaper than you think, depending on the rules and local environment. In any case, it's a major investment. And you can certainly have a rewarding practice without ever buying into an ASC.
 
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BW15

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Thanks for the advice. Any advice on which insurance companies to apply for? Is there a way to see which ones are better than others? Should I just apply for all of them in the area I want to work in?
 

gdub25

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Apply for all of them. Without joining a group and having no inside knowledge about who has favorable reimbursement, who is difficult to get paid from, who has strict prior authorization requirements, etc you’re going to have to learn by trial and error. You can also check to see if there’s an IPA (independent physicians association) that you can join who can help with contracting.
 

Ligament

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Yes, start on the ASC now. I worked on opening one for six years and it still failed.
 

Ligament

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What were the reasons for it failing if you don’t mind me asking?
Endless bureaucracy at the State Level with the Fire Chief, who supposedly was not showing up to work most of the time, construction needs dictated by said fire chief then those needs changed by replacement fire chief, etc etc. Dragged on for years. Just one of the many issues.

As this dragged on year after year, Obamacare weakened the remaining private practices in the area. Private practices could no longer afford to keep their doors open. They sold out to the local hospital. The local corporate hospital system purchased all the private practices that used to be referral sources, and would not allow their newly indentured physicians to refer outside of the system.

This effectively killed the referral base, which is ultimately the plan of these hospital systems; kill private practice.

So by the time there was some moderate progress from the state bureaucrats, the referral source had dried up thanks to the federal bureaucrats (Obama), and that was that.

So the next step in the plan is to move toward socialized medicine, where these employed physicians will be completely helpless but to accept it; there wlll be no way for them to return to private practice since private practice viability has been all but killed off.
 
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drusso

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Endless bureaucracy at the State Level with the Fire Chief, who supposedly was not showing up to work most of the time, construction needs dictated by said fire chief then those needs changed by replacement fire chief, etc etc. Dragged on for years. Just one of the many issues.

As this dragged on year after year, Obamacare weakened the remaining private practices in the area. Private practices could no longer afford to keep their doors open. They sold out to the local hospital. The local corporate hospital system purchased all the private practices that used to be referral sources, and would not allow their newly indentured physicians to refer outside of the system.

This effectively killed the referral base, which is ultimately the plan of these hospital systems; kill private practice.

So by the time there was some moderate progress from the state bureaucrats, the referral source had dried up thanks to the federal bureaucrats (Obama), and that was that.

So the next step in the plan is to move toward socialized medicine, where these employed physicians will be completely helpless but to accept it; there wlll be no way for them to return to private practice since private practice viability has been all but killed off.
This is happening all over the country. How did doctors succumb to this???
 

Ligament

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This is happening all over the country. How did doctors succumb to this???
Medical schools selecting for lemming personality traits in medical students. Systemic programming of medical students to be socialistic, mindless employed drones following algorithmic medical decision making. Systemic deprogramming of entrepreneurial ambitions during medical school. Purposeful neglect in teaching medical students about business.

When I talk to pre-med students they are all very aware that unless they endorse socialized medicine and free health care for all, they will never be admitted to medical school. Unless they say they want to work in a free clinic as a primary care doc being yelled at all day, they will never be admitted. They know what rightspeak and wrongthink is.

I've not met a single pre-med that says "I want to have my own private practice"
 
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BW15

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Apply for all of them. Without joining a group and having no inside knowledge about who has favorable reimbursement, who is difficult to get paid from, who has strict prior authorization requirements, etc you’re going to have to learn by trial and error. You can also check to see if there’s an IPA (independent physicians association) that you can join who can help with contracting.
Thanks for the advice, I'll just apply to all of them since I'll need all the patients I can get in the beginning.
 
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BW15

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Endless bureaucracy at the State Level with the Fire Chief, who supposedly was not showing up to work most of the time, construction needs dictated by said fire chief then those needs changed by replacement fire chief, etc etc. Dragged on for years. Just one of the many issues.

As this dragged on year after year, Obamacare weakened the remaining private practices in the area. Private practices could no longer afford to keep their doors open. They sold out to the local hospital. The local corporate hospital system purchased all the private practices that used to be referral sources, and would not allow their newly indentured physicians to refer outside of the system.

This effectively killed the referral base, which is ultimately the plan of these hospital systems; kill private practice.

So by the time there was some moderate progress from the state bureaucrats, the referral source had dried up thanks to the federal bureaucrats (Obama), and that was that.

So the next step in the plan is to move toward socialized medicine, where these employed physicians will be completely helpless but to accept it; there wlll be no way for them to return to private practice since private practice viability has been all but killed off.

The more I look into ASCs the more I realize that it may just not be possible for me. I read on another website that an optho single specialty ASC would generate about 150-400k/year after expenses if running proficiently. I thought it would generate more than that given its such a big investment to start one. I'll still look into the requirements for the city I want to practice in, but for now I guess I'll just work on building my practice and a procedure room.

Thanks for the input.
 

hyperalgesia

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The more I look into ASCs the more I realize that it may just not be possible for me. I read on another website that an optho single specialty ASC would generate about 150-400k/year after expenses if running proficiently. I thought it would generate more than that given its such a big investment to start one. I'll still look into the requirements for the city I want to practice in, but for now I guess I'll just work on building my practice and a procedure room.

Thanks for the input.
It certainly may be possible and worth it for you at some point but you're on the right track by focusing on the patient referral base first. That will be the horse that pulls the cart...
 

drpainfree

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Endless bureaucracy at the State Level with the Fire Chief, who supposedly was not showing up to work most of the time, construction needs dictated by said fire chief then those needs changed by replacement fire chief, etc etc. Dragged on for years. Just one of the many issues.

As this dragged on year after year, Obamacare weakened the remaining private practices in the area. Private practices could no longer afford to keep their doors open. They sold out to the local hospital. The local corporate hospital system purchased all the private practices that used to be referral sources, and would not allow their newly indentured physicians to refer outside of the system.

This effectively killed the referral base, which is ultimately the plan of these hospital systems; kill private practice.

So by the time there was some moderate progress from the state bureaucrats, the referral source had dried up thanks to the federal bureaucrats (Obama), and that was that.

So the next step in the plan is to move toward socialized medicine, where these employed physicians will be completely helpless but to accept it; there wlll be no way for them to return to private practice since private practice viability has been all but killed off.
were you building a single speciality ASC for pain management (basically for yourself) or part of multi-specialty surgery center with multiple docs? It sounds to me it was the latter. I think that might be your problem.
 

Ligament

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were you building a single speciality ASC for pain management (basically for yourself) or part of multi-specialty surgery center with multiple docs? It sounds to me it was the latter. I think that might be your problem.
You are correct, it was the latter, but privately owned.
 

promethius

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As someone who recently started my own practice, I may be able to provide some helpful advice. I would start credentialing and contracting about 6-9 months before you plan to see your first patient. I did all my own credentialing and contracting myself, and it took about that long for all the contracts to be signed and implemented. You should be able to get away with using a post office box as your office address for credentialing purposes and then change it to your actual office address before you start, so you will not have to pay any rent while you are waiting. You may also be surprised to find out that some insurances are closed for new providers if you are in a saturated market, so better to know that before you have already signed a lease.

As for part-time work, you can consider locums in your area. No long-time contracts and no non-compete clauses. Pay is also pretty good. If you want to do locums for pain, you can also request to do just procedures with no medication management.

As many before me have stated, and I cannot re-emphasize enough, the key to maintain viability with any start-up practice is to keep your overhead low. You will not be busy for months, and it usually takes 2-3 years for a practice to mature, so you do not need too many staff right away. In fact, I would actually advocate doing as much as you can yourself. Treat your first year running your own practice as a continuation of your fellowship, where you are learning the business side of medicine. Learn how to do prior authorizations, file claims, and keep track of and order supplies. Talk to vendors and see what is out there. If you know all the different aspects of running a practice, your practice will not shut down when someone calls out sick or leaves and you will know if your practice is being mismanaged.

From conservative to most aggressive, you can start a practice without an in-office procedure room, with an in-office procedure room, and with an ASC. I would not consider starting an ASC until your practice can support one because of the extra overhead and regulations involved. If you want to collect the "facility fee" for doing procedures, invest in an in-office procedure room and re-evaluate after 1-2 years. You may be surprised at how few procedures you will be doing during your first year because it will take time to build a patient base for procedures.

One of the lyrics in that popular 1999 Sunscreen song best sums it up: "The race is long and in the end, it's only with yourself."
 
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drusso

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As someone who recently started my own practice, I may be able to provide some helpful advice. I would start credentialing and contracting about 6-9 months before you plan to see your first patient. I did all my own credentialing and contracting myself, and it took about that long for all the contracts to be signed and implemented. You should be able to get away with using a post office box as your office address for credentialing purposes and then change it to your actual office address before you start, so you will not have to pay any rent while you are waiting. You may also be surprised to find out that some insurances are closed for new providers if you are in a saturated market, so better to know that before you have already signed a lease.

As for part-time work, you can consider locums in your area. No long-time contracts and no non-compete clauses. Pay is also pretty good. If you want to do locums for pain, you can also request to do just procedures with no medication management.

As many before me have stated, and I cannot re-emphasize enough, the key to maintain viability with any start-up practice is to keep your overhead low. You will not be busy for months, and it usually takes 2-3 years for a practice to mature, so you do not need too many staff right away. In fact, I would actually advocate doing as much as you can yourself. Treat your first year running your own practice as a continuation of your fellowship, where you are learning the business side of medicine. Learn how to do prior authorizations, file claims, and keep track of and order supplies. Talk to vendors and see what is out there. If you know all the different aspects of running a practice, your practice will not shut down when someone calls out sick or leaves and you will know if your practice is being mismanaged.

From conservative to most aggressive, you can start a practice without an in-office procedure room, with an in-office procedure room, and with an ASC. I would not consider starting an ASC until your practice can support one because of the extra overhead and regulations involved. If you want to collect the "facility fee" for doing procedures, invest in an in-office procedure room and re-evaluate after 1-2 years. You may be surprised at how few procedures you will be doing during your first year because it will take time to build a patient base for procedures.

One of the lyrics in that popular 1999 Sunscreen song best sums it up: "The race is long and in the end, it's only with yourself."
Be sure to go back and give a lecture to your residency/fellowship program about nuts and bolts of self-employment!
 
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Not to hijack the thread...but I have a guy thats going to charge me 10k to get credentialed with 18 insurances including medicare. Does this sound fair?