starting own pain practice

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promethius

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Ever since I finished my fellowship a few years ago, the end goal was always to start my own outpatient pain practice. I have worked for a few years now as an employed physician, found out what I liked and didn't like about the practice I am working for, and most importantly, how I would like to see chronic pain patients, so they can receive the best possible care. I am ready now as I will ever be to take the leap.

I did a search and found a couple of threads about this topic, but to be honest, I do not know where to even start. I hear that it is helpful to get a lawyer and consultant involved, at least initially. What is a checklist of things I should do to even set-up a practice? Anything I should avoid or be wary of? I am also thinking of partnering up with a non-orthopedic surgeon I have known for a while now who does mostly outpatient procedures to cut down on the overhead costs. What are your thoughts on the pros and cons of doing that?

Lastly, I know that it may take 1-2 years before the practice even begins to pick up. Besides marketing and networking, what have other physicians done during that time? Did anyone do any moonlighting or locums in the local area to make some extra money? Anyone know of a good locums group that caters specifically to pain physicians? I appreciate any and all input!
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There are many areas that are competitive for referrals with some neurosurgeons and ortho spine surgeons referring to their in-house employee pain physicians, or do the procedures (including SCS and RF) themselves. So discovering the referral patterns is very important before you begin, and sometimes the secretaries of the ortho/neuro/FP will be quite illuminating. Obtaining credentialing and enrolling in panels of insurers is also a very important early step. Some insurances do not want any more physicians performing injections. Setting the tone of the practice is important- esp. to PCPs. What can you do for them that will make their lives better dealing with pain patients and yet not becoming a pill dump. Doing procedures in a hospital or surgery center initially will trade some Medicare income and efficiency for good will and perhaps a referral base. Look at state laws regarding office procedures, federal law templates for HIPAA and OSHA. Disposal of needles (vendors to collect and replace used needle plastic receptacles), EMR, fluoro, procedure table, setting up accounts for purchasing medications (Clint Pharmaceuticals is more expensive but is a good place to start), and secretarial services are early costs. My experience with consultants is they cost way too much, unless you are building a surgery center.
 
promethius said:
Ever since I finished my fellowship a few years ago, the end goal was always to start my own outpatient pain practice. I have worked for a few years now as an employed physician, found out what I liked and didn't like about the practice I am working for, and most importantly, how I would like to see chronic pain patients, so they can receive the best possible care. I am ready now as I will ever be to take the leap.

I did a search and found a couple of threads about this topic, but to be honest, I do not know where to even start. I hear that it is helpful to get a lawyer and consultant involved, at least initially. What is a checklist of things I should do to even set-up a practice? Anything I should avoid or be wary of? I am also thinking of partnering up with a non-orthopedic surgeon I have known for a while now who does mostly outpatient procedures to cut down on the overhead costs. What are your thoughts on the pros and cons of doing that?

Lastly, I know that it may take 1-2 years before the practice even begins to pick up. Besides marketing and networking, what have other physicians done during that time? Did anyone do any moonlighting or locums in the local area to make some extra money? Anyone know of a good locums group that caters specifically to pain physicians? I appreciate any and all input!
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If you build it, they will come...
 
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This thread has more info than you need to start a practice.
Identifying the location that you see yourself living 10-15 years from now is key.
The attached checklist is comprehensive.
 

Attachments

Most important thing is getting on the right insurance plans. The other things can be worked on/developed slowly, but not being able to contract with the right plans in your area can block you from even having a chance at making it.

Cost sharing with other physicians is good. Especially in this environment. Might be difficulty to do it with a surgeon unless it's Ortho or Neurosurg, as surgeons in specialties that don't work much with pain mgmt. doctors are likely to have very different needs than you.

You'll probably need some part-time or independent contractor work in the beginning. The best types are those that help develop or directly feed into your own practice in some fashion.
 
bronchospasm said:
This thread has more info than you need to start a practice.
Identifying the location that you see yourself living 10-15 years from now is key.
The attached checklist is comprehensive.
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This list is very good!

There is SO MUCH you need to do, particularly if you are taking insurance.
 
Getting credentialed by insurers and obtaining a steady, diverse flow of patient referrals are the two biggest hurdles to owning your own gig. The rest is obtainable....


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Disciple said:
Most important thing is getting on the right insurance plans. The other things can be worked on/developed slowly, but not being able to contract with the right plans in your area can block you from even having a chance at making it.

Cost sharing with other physicians is good. Especially in this environment. Might be difficulty to do it with a surgeon unless it's Ortho or Neurosurg, as surgeons in specialties that don't work much with pain mgmt. doctors are likely to have very different needs than you.

You'll probably need some part-time or independent contractor work in the beginning. The best types are those that help develop or directly feed into your own practice in some fashion.
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Contact device reps about locations that might be best (?underserved)

I did lunch lectures at local senior centers (bring food and chance to hear from a doctor and every senior within 50
Miles will be there)

Make sure Pcp and other referrals know what patients you do and don't want.

If you can make their job a little easier it will lead to possibly all their referrals.
For instance some competitors will not touch a new patient without an up to date MRI. If you tell them you will get it they will be inclined to send your way. A lot of docs judge who to send to based on how many headache they reduce
 
myrandom2003 said:
Have you used/using this service/company?

I assume you are happy with what they provided you since you recommended it here.
What did they exactly do for you?
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They do a lot of things but credentialing is their forte. Penny is the lead person there. Very knowledgeable about the whole process. They charged me $2k for 10 insurance credentialing. This was 4 years ago. They are approved by MGMA.

Highly recommend.
 
Sorry for being MIA, but I have been busy the past few weeks putting in the leg work to get my practice up and running. I appreciate all the helpful replies and referrals on this thread.

If I plan to practice within the same geographical area (within 25 miles) as my last practice, do I need to get re-credentialed again, or can I just use the same credentialing I had with my last practice? Should I contact my last practice for a list of insurers I am currently credentialed with to save time and resources, so I am not reinventing the wheel again? Also, how feasible is it to do credentialing on your own versus going through a credentialing company, such as the one bronchospasm recommended?

As a side note, what do you all think about non-compete clauses in employment contracts? Are they actually enforceable in a court of law? I appreciate all of your input.
 
Non competes can be enforced in most locations, but cannot be overly broad geographically or excessively lengthy (more than 2 years). The potential degree of the departing doctor affecting their current business will be one of the main factors in whether litigation is pursued. Sometimes a buyout of a non-compete is possible. In addition to a non-compete, there are also non-solicitation clauses in contracts preventing contacting former patients about the practice, and in some cases, advertising your new whereabouts, although usually only the former is enforced. Such clauses are triggered if any advertisement you place has "formerly at X practice". As for credentialing, in my experience recredentialing was required even though you have an active number with a specific insurer.
 
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Non compete will vary state by state. Can usually find state specific information that gives you an idea with a search. Even in states without enforceable non-compete, may still have to pay reasonable liquidated damages. As algos said, the enforceability can also vary depending upon the circumstances and reasonableness of the non-compete.
 
So I am thinking of getting a C-arm and a separate x-ray machine for my practice. What manufacturers and/or vendors do you recommend contacting regarding information on these imaging machines? Other than lead walls, other there any other codes or specifications (i.e. what to do with windows, minimum room size requirement, etc.) I should be aware of for a room that is to be fitted with x-ray equipment?

Also, on an unrelated topic, what do you think about getting hospital privileges for an outpatient-based pain physician? I know of both types of pain practitioners, one who do have and ones who do not have hospital privileges. Just curious to know what the pros (increased referrals?) and cons (yearly membership dues? more paperwork to meet the requirements of getting and staying privileged?) of getting privileged at a hospital are if I plan to be solely office/ASC-based and not set foot in a hospital. Thank you for your feedback!
 
promethius said:
So I am thinking of getting a C-arm and a separate x-ray machine for my practice. What manufacturers and/or vendors do you recommend contacting regarding information on these imaging machines? Other than lead walls, other there any other codes or specifications (i.e. what to do with windows, minimum room size requirement, etc.) I should be aware of for a room that is to be fitted with x-ray equipment?

Also, on an unrelated topic, what do you think about getting hospital privileges for an outpatient-based pain physician? I know of both types of pain practitioners, one who do have and ones who do not have hospital privileges. Just curious to know what the pros (increased referrals?) and cons (yearly membership dues? more paperwork to meet the requirements of getting and staying privileged?) of getting privileged at a hospital are if I plan to be solely office/ASC-based and not set foot in a hospital. Thank you for your feedback!
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I would call OEC and Philips to get contact info for their local reps. These guys will be very helpful. You will probably need a medical physics person from the state to come and test your room and neighboring rooms for radiation from the machine to determine if you need lead lining. Lead is not usually required, at least for a c-arm. Not sure about a fixed machine. Regulations vary by state but the reps are a good bet for local info (especially if they agree). You can also contact your state radiation safety section (that's what it's called in my state). Part of your state dept of health. In my state, they are the ones who send the physics guy out to certify the c-arm setup.

I am credentialed at several hospitals and it has been very low yield in terms of consults. Actually, it has been zero yield. It's not very expensive (maybe $200 every 2 years) but things like mandatory flu shots and of course PPD or you have to wear a mask all day. CME, sometimes ACLS, etc. 3 people have to submit reference questionnaires every 2 years. It's a PITA but maybe worth it for one hospital, at least at the beginning. You can expect to have an issue of some kind or another with your ASC at some point so it's nice to have a back up. Maybe you want to chat with the radiologists at the hospital and the spine surgeons. It can be helpful to know people in a hospital. Maybe it also helps a tiny bit in the beginning in terms of reputation and community integration. If used properly, it can probably be used to scare up some referrals.
 
Not to thread jack, but a quick side question.

Do you need to be ACGME fellowship trained to obtain hospital privileges and to get credentialed with insurance companies?
 
Blitz2006 said:
Not to thread jack, but a quick side question.

Do you need to be ACGME fellowship trained to obtain hospital privileges and to get credentialed with insurance companies?
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no, hospital and local insurance carrier dependent.

a rural midwest or deep south hospital probably is less stringent than a northestern large hospital system.
 
So I am getting different information from different sales representatives. Do you know if the C-arm procedure room requires leaded walls and doors? I also read earlier in a previous post on here that special flooring needs to be installed for the C-arm procedure room. Is that true? Thanks!
 
promethius said:
So I am getting different information from different sales representatives. Do you know if the C-arm procedure room requires leaded walls and doors? I also read earlier in a previous post on here that special flooring needs to be installed for the C-arm procedure room. Is that true? Thanks!
Click to expand...

Depends upon the state. Some walls, some doors, some both. Check with the ortho's and dentists in your town.
 
promethius said:
So I am getting different information from different sales representatives. Do you know if the C-arm procedure room requires leaded walls and doors? I also read earlier in a previous post on here that special flooring needs to be installed for the C-arm procedure room. Is that true? Thanks!
Click to expand...

Floors?
 
If you're on the second floor you may need to lead the floor. For leaded walls you can just put up lead lined drywall. Not that hard to put up yourself if you are inclined to do so. You may not need to do any of this. Call your state's department of health or whoever will issue the license for your fluoro unit. They will tell you what the requirements are. I think it was mentioned above, you'll most likely need a physicist to evaluate your set up prior to passing you for a license. The physicist will most likely be able to tell you what you'll need in terms of leaded material.
 
Oral Surg Oral Med Oral Pathol. 1983 Mar;55(3):319-26.
Drywall construction as a dental radiation barrier.
MacDonald JC, Reid JA, Berthoty D.
Abstract
Six typical forms of drywall construction have been tested as barriers against primary and secondary dental x-radiation. It is concluded that this widely used type of wall construction is generally effective for this purpose, but with a heavy workload two thicknesses of wallboard on each side of the wall are required to provide a sufficient barrier. In general, no lead need be incorporated in the walls.
 
Pain Applicant1 said:
If you're on the second floor you may need to lead the floor. For leaded walls you can just put up lead lined drywall. Not that hard to put up yourself if you are inclined to do so. You may not need to do any of this. Call your state's department of health or whoever will issue the license for your fluoro unit. They will tell you what the requirements are. I think it was mentioned above, you'll most likely need a physicist to evaluate your set up prior to passing you for a license. The physicist will most likely be able to tell you what you'll need in terms of leaded material.
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I think any floor that supports a c-arm would have more than enough radiation protection from a C-arm
 
I called around to some of the medical physicists. Apparently ceilings and floors have to be properly shielded too if you are in a multi-storied building, so it is much easier to set up a radiation source in a single-level building.

What are the major medical vendors everyone has been using for medical supplies, especially as it pertains to a pain management practice? Common ones I have heard of are Medline and McKesson. Any other ones? Which one offers the most competitive prices?
 
(1) Henry-schein is another. (2) Invite reps from each company to visit. They’ll make a list of what you want and give discounts. Don’t pay retail for stuff you use alot. Have your MA compare price of each item every time (or at least periodically). We cherrypick between all 3 companies. Compare price of a kit versus syringes, needle etc on sterile mayo stand. Good luck.
 
For the people that run their own practice, what kind of insurances and indemnities are you carrying apart from professional liability? Do you carry umbrella insurance for slips and falls?
 
Good advice kamilo6 and mickey1t. Medline, McKesson, and Henry Schein. Are we missing any other major vendors for medical office supplies?

Maybe some of the more experienced peanut gallery members can correct me if I am wrong, but as for small business insurance, I don't think you need umbrella coverage if you already have personal injury liability with the standard $1 million per occurrence and $2 million aggregate limits. I personally found that adding umbrella coverage to increase those limits by another $1 million will increase your insurance premiums by $300-$400 a year.
 
Clint Pharmaceutical is a good one stop shopping site. They do not use any compounded meds and have block trays, syringes, and supplies
 
They can indeed be higher than other vendors, but they offer rapid service when it is needed, and can be a great way to dip your toes into pain management.
 
Just shop around.

I would avoid block trays to start. You can do cheaper.
 
What is everyone doing for malpractice insurance? Any recommendations for insurance companies that offer coverage at affordable rates? Are $1 million/$3 million limits standard for most pain practitioners?
 
Clint pharmaceuticals is a great, Christian family owned company. Nice service. Prices are higher but they have everything you need and are reliable. Have been in business a long time.
 
Ligament said:
Clint pharmaceuticals is a great, Christian family owned company. Nice service. Prices are higher but they have everything you need and are reliable. Have been in business a long time.
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Do you know of a Jewish-based company?
 
Anybody have any experience custom building their own clinic? I think a multi specialty clinic space could be a good investment. Family docs/IM/pain/ortho all paying rent. Sharing lab and X-ray makes things complicated.
 
Which vendors are you using for your urine drug testing? I have only worked with Millennium Health. Just wondering if there are other major companies that are doing the urine drug testing. Are you doing the screening tests before sending for confirmation or just sending for confirmation? Not sure how true it is, but I heard insurance companies are increasingly not covering the urine drug screenings, so physicians are increasingly opting out of the urine drug screenings for just the confirmation.
 
Who is still doing the urine drug screens versus not doing the screens at all and just sending for confirmation? Is it true that insurance companies are increasingly not covering the urine drug screens? Regarding billing for the urine drug screens, is the billing code the same regardless of how many drugs you test for on either the point-of-care cup or dip card?
 
If you’re doing POC in office you need to use a Clia-waived cup unless you have a Clia certification. The reimbursement is flat rate per code and there isn’t a greater complexity code. The cups are about $5 a unit in bulk and I charge $20 so if insurance doesn’t reimburse you it’s not terrible if the patient gets billed.
 
I am trying to learn as much as possible about the administrative side of owning my own practice, as I may need to know how to run things if my staff either do not know or are off. Having said that, do either you or your staff verify patients' insurances and benefits before they come for their first appointment? What do you ask them over the phone, so you can check their insurance before they actually come? How do Tricare/Medicare/Medicaid differ from commercial insurances in regards to copayments, deductibles, coinsurances, etc. that your office is responsible for collecting at the time of visit? Thanks!
 
promethius said:
I am trying to learn as much as possible about the administrative side of owning my own practice, as I may need to know how to run things if my staff either do not know or are off. Having said that, do either you or your staff verify patients' insurances and benefits before they come for their first appointment? What do you ask them over the phone, so you can check their insurance before they actually come? How do Tricare/Medicare/Medicaid differ from commercial insurances in regards to copayments, deductibles, coinsurances, etc. that your office is responsible for collecting at the time of visit? Thanks!
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Not knowing this basic info means you are probably not ready to open your own shop just yet. It would probably be worth it to hire a consultant to guide you through this process. Yes they can be expensive, but less than potential losses of incorrect billing, collections, etc
 
promethius said:
I am trying to learn as much as possible about the administrative side of owning my own practice, as I may need to know how to run things if my staff either do not know or are off. Having said that, do either you or your staff verify patients' insurances and benefits before they come for their first appointment? What do you ask them over the phone, so you can check their insurance before they actually come? How do Tricare/Medicare/Medicaid differ from commercial insurances in regards to copayments, deductibles, coinsurances, etc. that your office is responsible for collecting at the time of visit? Thanks!
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sorry but if at this point you don't know how medicare differs from commericial in regards to copays, etc and whether or not your office is responsible for collecting. I would highly reccomened you do not open up your own practice
 
promethius said:
I am trying to learn as much as possible about the administrative side of owning my own practice, as I may need to know how to run things if my staff either do not know or are off. Having said that, do either you or your staff verify patients' insurances and benefits before they come for their first appointment? What do you ask them over the phone, so you can check their insurance before they actually come? How do Tricare/Medicare/Medicaid differ from commercial insurances in regards to copayments, deductibles, coinsurances, etc. that your office is responsible for collecting at the time of visit? Thanks!
Click to expand...
In my practice, my scheduler screens the pt to make sure they're in the right place, they're not a drug addict looking for oxy, and they have good insurance. We take insurance info and schedule them.

When (if) they get to the office, we photocopy the insurance and ID and they fill out the paperwork. At this time, many practices will figure out the copay, deductible, while the pt is waiting and being seen. Determining their eligibility can be complicated and time consuming. For my set up, it's not worth the time unless it's a pre-auth for a procedure.

So we generally don't collect copay at the visit. We bill the insurance/Medicare. In a few weeks usually, we get a response called EOB that explains what the copay is and we send invoice to the pt or secondary insurance. I've had a few pts not pay their co-pay. They also don't return. For my set up, it's worth it. I think of it as an occasional "free consultation".

My advice when setting up a practice is to have another source of income, start out part-time, subleasing office space, 1099 employee (if that), etc. In this set up, there are docs who do their own scheduling at first and there's no shame in this. In all business ventures, my philosophy is the overhead should follow the demand, not the other way around.
 
My staff ALWAYS estimates co-insurance/deductible/copay and collects before patient is seen. I end up writing 20 small refund checks a quarter to patients. U are the last person in the world the turnip(patient) will prioritize to pay if you send a bill.
 
I appreciate the constructive feedback. Running one's own practice is different from working for someone else where you are just responsible for seeing and taking care of patients. Don't get me wrong; I understand what copays, deductibles, and coinsurances are. It is just that different insurances use different systems for verifying and tracking benefits, and it can be difficult to keep track of all the differences at least in the beginning when you are a solo practitioner building a practice from the ground up.

Sounds like different practitioners have different philosophies about verifying benefits and collecting patient expenses, which is what I thought would be the case. I plan to start slow and build up my practice while I learn the ins-and-outs of the business side of medicine. If I make any mistakes, it will be better to do so early on when I am not as busy.
 
promethius said:
I appreciate the constructive feedback. Running one's own practice is different from working for someone else where you are just responsible for seeing and taking care of patients. Don't get me wrong; I understand what copays, deductibles, and coinsurances are. It is just that different insurances use different systems for verifying and tracking benefits, and it can be difficult to keep track of all the differences at least in the beginning when you are a solo practitioner building a practice from the ground up.

Sounds like different practitioners have different philosophies about verifying benefits and collecting patient expenses, which is what I thought would be the case. I plan to start slow and build up my practice while I learn the ins-and-outs of the business side of medicine. If I make any mistakes, it will be better to do so early on when I am not as busy.
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Take a billing course from ASIPP.

Also if you have the flexibility invest in an EMR that will do verification for you.

Good luck! Toughest part is getting on panel (atleast in Florida). Get your Medicare application submitted ASAP, complete caqh asap, and then hit the ground talking to other providers for referrals and establishing meaningful long term relationships. There is a subset of people out there that will see you for cash (e.g. altered comfort crowd).

Im sure someone will correct me but you can retroactively bill for Medicare up to a certain time period.

Establish a relationship with an ASC if you want to do procedures in the early run since cash flow will be tight.

Keep overhead low. Live within your means. With a little luck and a lot of ground work you will grow slowly.

What state are you in? PM me for more info/details.
 
hyperalgesia said:
My advice when setting up a practice is to have another source of income, start out part-time, subleasing office space, 1099 employee (if that), etc. In this set up, there are docs who do their own scheduling at first and there's no shame in this. In all business ventures, my philosophy is the overhead should follow the demand, not the other way around.
Click to expand...

My understanding was that there are very limited circumstances under which you ought to set your initial employee up as a 1099. Even if they're part time, but they still function as a salaried employee (ie: hourly wage, you control their hours, you can fire them, etc), shouldn't they be set up as a W-2 in order to avoid risking penalties and fines for not paying payroll taxes?
 
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