Looking for experienced owners to poke holes in my dreams! Seriously, beat the crap out of them so things are realistic! (LONG)

[SmokeyBear]

This is a long wall of text. Only read if you're bored. 

Backstory

About me: I've been practicing for about 9 years now. I worked for 5 years in an FQHC which was super informative in the whole aspect of sink or swim, you learn to tread water super fast when your SP is 50 miles away and never available by phone. I did not love this job, but was in it for the loan repayment. Left as soon as I'd maxed loan forgiveness with the state. 

I then spent 3 years working in a tiny retail clinic outside Seattle, walk in only, could only schedule online, same day stuff. Not UC, so no EKGs, no imaging on site, no labs other than POC stuff. I LOVED this job. Worked 3-12's and absolutely loved having 4 days off a week. Pay was good, patients were low acuity, and anyone who was really sick was punted to an actual UC or the ED. Everyone got the "follow up with PCP" comment, which felt so good not to be that PCP that patients needed to f/u with.

Neither of these jobs had very much interaction with SPs, so I was basically practicing independently. SP oversight was them signing off on 10% of my charts per month, which I'm not even sure if they technically did this. In these 8ish years, I had 3 SPs. In those 8 years I met face to face with an SP maybe 4-5 times. I never even met my third SP, ever. We emailed a couple times, that was it.

Then Covid hit and the company closed all the retail clinics. It was scary... super scary... I applied to 42 jobs that I was overqualified for, and it took 7 months to get an offer. Who knew there'd be such a hard time to land a new job as a medical provider in the middle of a pandemic? Everyone had hiring freezes. That finally thawed, and I landed in House Calls. I'm not in love with house calls... The patients are... oof... Seeing the way these folks live in situ is bizarre. I'd never have guessed so high a percentage of the general pop are hoarders. In the first few months I'd been exposed to Covid, scabies, roaches, mice infestations, massive pitbull in my face, many tiny dogs in my face, ungodly amounts of animal excrement, the list goes on and on. Needless to say other opportunities are looking better and better as the days go by. 

I've never run a business. I have business owners in the family and have support from their aspects, however none of them work in healthcare. The closest thing to a business I've personally done is running an eBay store, which is essentially just a side gig/hobby and has been for 20 years. It brings in less than $10k annually, but its spending cash and pays for fun things like airfare or cruises. 

 

The Idea and questions: 

I'm now in a state which now allows for independent practice with 10,000 hours experience in a specific field. As I have well over the 10k hrs in Family Med, I'm kicking around the following idea: 

Super small same day family practice care. Very similar to the retail clinic I was working in. Our local UCs are so bombarded right now that people are waiting 2-4 hours just to be seen. My goal would be to siphon some of those patients to my small practice. By small, I'm thinking solo... if not solo, then maaaaybe an MA. Small like possibly having my wife get licensed as an MA... Small like a single room clinic without a front desk or a break room and the likes. When I was in the retail clinic we had two tiny rooms, each with an exam table, a computer and printer in each room, a tiny supply closet... that's about it.  Personnel wise It was just me and occasionally an MA, so I'm used to doing the check in and registration and vitals and all the parts of an entire visit from when the patient presents to the front door. That part doesn't scare me. Insurance companies do scare me, failure also moderately scares me, and un-planned or un-accounted for costs associated with business also scares me. 

Initially I thought "Cash pay-all the way!", in the retail setting the cash pay patients were always so easy. However, I'm in an area where the vast majority of the population is insured in one way or another. The folks are usually frugal, and are going to weigh a cash pay option vs the wait time in the UC where their insurance will be billed. Pay me $100 and get seen now, or wait 2-4 hours at the UC and pay almost nothing (depending on what their ins is, where they're at with deductible and OOP for the year etc...) I'm just not sure that cash pay is the right way in a population that is heavily insured. If I was back in FQHC territory, I think cash pay would be the ticket still. 

So.. That leads me to insurances. I'd have to apply as an independent provider to be credentialed with at least the big 3-4 insurance providers in this area. Should I even bother with Medicare/Medicaid? These two are giving me the most heartburn when I think about my plans. Not accepting medicare instantly cuts out a huge swath of insured patients with super easy complaints like cerumen impactions and simple derm procedures. However this population is also more sick, and even if only dealing with one simple complaint, there's a ton of polypharmacy to consider when treating anything from strep throat to diarrhea.  Is it worth credentialing and dealing with federal HA? Or avoid the headaches with the state/fed payors and go with a cash pay/private insurance model? 

What do reimbursements even look like for things like 99213 vs 99203? I literally don't know what payments look like as I've just "seen the patient" for 9 years. I've tried looking this up for private insurance, but the google searches always throw medicare payments at my search results. The info is out there, but buried I'm sure. Is private insurance a higher reimbursement than medicare? Or do they typically follow the medicare pricing model? 

Just going off the medicare pricing though.. If I could see just 15 patients per day, i'd still make quite a bit more than I make now. I realize the number I get doing the maths on this isn't my potential salary. There's overhead/costs like building lease, office supplies, power, internet, other utilities, my own malpractice policy, taxes... Not to mention I'd now have to come out of pocket for personal and family  health and life insurance, my own 401K without matching, CME, plan for PTO and all the stuff that's offered by my employer...  But even if all of those things added up to 50% of the reimbursed amount, the other 50% is still more than my current salary... I'm also not sure how you delineate business income vs personal salary?? Do business taxes become your income tax? I realize yall aren't my lawyer(s) here, but before I contact a lawyer and draw this up for real, I want to flesh this out for a minute. 

You've made it to the end! Congrats for wasting so much of your day. Now hit me with your thoughts! 

I've probably forgotten something I wanted to say. But this is the gist of it. So, poke holes, tell me I'm foolish, it'll never work... But give reasons why... Not just "you're crazy..." 

 

Thanks in advance! 


 

 

 

[jmj11]

I owned my own practice in Washington state for 5 years. The things you worry about, are worry-worthy. I worked through the same process. If I had it to do over, like you said, I would have stayed small. I spent too much on overhead, EMR, etc. Keep those cost low. I know someone doing exactly what you are thinking, but she is having a hard time creating enough business as patients aren't that willing to give up the physician they know, even if they have to wait, than to go to a more convenient but PA - owned practice. Higher population density can help. Insurance companies are like sleeping with the devil. It is hard to live without them, hard to live with them. My biggest challenge in the area was Group Health, now Kaiser. They signed a contract with me but then (due to their own internal glitches) never paid me a dime, which killed my clinic. Almost took them to court but my lawyers advised against it because it would cost me 250K to recover 60k. Life is not fair and insurance companies can treat you like they wish. CMS was a lot of paperwork, low reimbursement, but didn't play games. My war with the insurance companies (mentioned above) took the fun out of it. My mentor (PA owner) gave me one bit of advise that proved true. Do a good business plan (you can buy books on creating business plans), then double your overhead and halve your collections and you will come out about to reality, at least in the beginning. One other thing I would advise. Try your best not to borrow money. Getting a business loan will create a huge amount of paper work and set your time schedule back at least 90 days if not six months. PM if you  have any questions.  Good luck

[rev ronin]

I'm running my own clinic in Washington state, and here's how I'm making it work:

1) LOW overhead. No employees, just me. Single room clinic.

2) Subspecialty (workers comp, complicated/long cases) where I have 6y experience and a good reputation with the local law firms, claim managers, and vocational counselors, not to mention the various other specialists I've referred to from my past practices.

3) No loans.

4) Only one insurance company to deal with at first, and I'm doing the billing all myself.  Unlike you, I've been responsible for coding my own visits essentially from my first job.

If I didn't have the network of local people who trusted me and the reimbursement rates, I couldn't make this work. For now, I'm looking reasonably good.

[ventana]

go for it

 

credential with medicare and take state medicaid as seconday only (single payor practice)

find a billing company that will include a simple EMR in the cost of their collections (should be 5-8% of collections)

 

skim the top

also get certified to do DOT/CDL exams for $100

 

it will work 

 

What state are you in??

[gsoames]

Practice owner for 3 years.  Accept all insurances doing primarily acute care house calls.

COVID was a boon for my practice, considering where I am, there is literally  no other mobile practice, and clinics were closing left and right, so my practice essentially became a mobile COVID testing practice.  Made $90,000 in one month (thats the max, though these days I never make less than $25,000/month.

You will want to accept Medicare.  Cash pay is great if you are in an affluent area.

Medicare is actually my best payor.  Private insurers seem to use every single trick in the book to not pay.  My first 18 months, I was often getting paid $0 despite being credentialed because billing for house calls is very tricky (for example, when you register a patient you have to list the full 9 digit zip code, without this you get no money).

It takes a lot more work when you are the practice owner.  You will likely fail unless you get some help like an MA or RN.  You have no idea the amount of paperwork that goes on behind the scenes that office staff manage at a regular practice.

[Bradshealth]

I have been researching solo ownership of a practice now for close to 18 months. I’m finally in that decision making stage. 
I too live an area where most people have insurance, but most of these insurance plans are crap! 
I’m working on a direct primary care space that will have both a pay for service or pay for regular access to care, prolonged visits, texts, phone call (Through a monthly membership fee). 
I’m only months away from opening my doors now, just finally several pieces of the puzzle! 
I’ve now practiced for 16 years and I’m ready to be my own boss. The direct care/ cash pay model will likely take long to build, but will alleviate massive headaches and back end work. 
I can make clear cut and fair from the beginning.

im leaning toward primary care plus sports Med, plus a little Dysautonomia. 

[VentiMacchiato]

Good luck! Check with DME supplier if they need a collab doc's signature in order to order supplies. 

Any updates from the OP?

My thoughts FWIW: (1) Calculate your "absolute break even $$." (2) patient may still ask you for the superbills so they can submit it themselves; (3) doing in house labs is not worth it; (4) OSHA is watching you but  they cannot touch you unless you have employees. (5) In the end, all you need is your brain and a stethoscope and maybe a sphygmomanometer to run a clinic. Everything else is bells and whistles. Keep it simple and grow slowly.