Starting a practice requires a sequence of coordinated
events that should begin at least 6 months prior to actually
beginning to see patients. Because it is virtually impossible
for a physician to both participate fully in a current practice
and singlehandedly manage the countless details needed to
implement a new practice (especially if transitioning from
one group to a new corporation), it is necessary to have
assistance. Such may be found in one of 3 ways: have
your spouse work on setting up the nuts and bolts of the
practice, hire a consultant firm to set up the practice, or
hire a college student to fill out forms while the physician
events that should begin at least 6 months prior to actually
beginning to see patients. Because it is virtually impossible
for a physician to both participate fully in a current practice
and singlehandedly manage the countless details needed to
implement a new practice (especially if transitioning from
one group to a new corporation), it is necessary to have
assistance. Such may be found in one of 3 ways: have
your spouse work on setting up the nuts and bolts of the
practice, hire a consultant firm to set up the practice, or
hire a college student to fill out forms while the physician
Making the Jump
An excellent Start Up Check List may be downloaded here.
TIME-LINE TO OPENING YOUR PRACTICE
6-12 months in advance
Make sure you have the appropriate training for the techniques, medication management, physical
examination, and diagnostic skills needed for your pain model. The ISIS courses are intensive
training in a well designed, anatomically and evidence based format for a particular technique. The
courses fill up quickly so apply in advance. PASSOR is another good choice for a survey of
techniques, while SPPM offers several 4 day cadaver courses with a comprehensive approach to
pain management, including billing, coding, and discussions on setting up a practice.
6 months in advance
1. Set up a corporation or LLC if that is to be your business legal entity. Often this can be done on
the internet via services or may be done by downloading forms for such from the Secretary of
State's (SOS) websites. The SOS websites may be found here . It may be prudent to contact the
SOS regarding the business corporation type that must be used. Some states require a PC or PA
for physicians while many do not. A lawyer will be happy to set up a medical corporation for
$500-$5,000, but for a single person corporation or small group, it is not necessary to bear the
expense. A generic example of Medical Articles of Incorporation may be downloaded in word
format here. It is also possible to pay services online to incorporate for you (search "incorporate
online). It is not necessary to incorporate out of state as there is not a significant advantage for
most physicians to do so. It is possible through most of the SOS offices to search online for
available corporate or LLC names. A corporate name trumps a sole proprietorship name, even if
the sole proprietor was in business first. In some states, it is possible to "reserve" a corporate
name for a small fee. The reserved name is usually good for several months during which time the
incorporation may proceed without fear of losing the chosen name. Remember, the bylaws of the
corporation and address may be changed by a vote of the shareholders, which is you, at virtually
any time. Therefore for the initial corporation address, one may use your home address initially.
Later an amendment is filed with the SOS for any address changes such as in the case of
acquisition of an office address (needed for application for Medicare number). Most physicians
form "C" Corporations, "S" Corporations, or LLC. Legal partnerships are not a good business form
for physicians unless a LLP is used, but even these are uncommon in medicine.
2. Once the incorporation papers have been approved by the SOS and received, then apply for a
federal tax ID number. You may apply online here, or you may seek out any of the several
commercial vendors which charge $10-25 for the same service.
3. Obtain a PO Box in the corporate name from your local post office. Information, box sizes, and
fees for PO Boxes may be found here.
4. If you are certain you are planning to change groups, give your current group as much notice as
possible, up to 6 months. This makes their recruitment much easier than a 90 or 120 day notice
being given. It may also smooth the transition period, reduce hostility, and demonstrate good will.
Most groups will be more accommodating if they believe you are acting in good faith. Remember,
your former anesthesiology partners may become your anesthesiologists for your cases in the
future. Similarly, former PM&R partners can be good referral sources in the future.
5. Obtain information from your own current billing agency regarding which insurance companies
with whom you may have contracts, and obtain the provider relations telephone numbers if possible.
Another approach is contacting the hospital billing office and ask for their list of top ten insurers with
provider relations numbers if possible. Obtain your UPIN and current Medicare numbers from your
billing service. Information on state by state Medicare carriers may be found here whereas
enrollment information may be found here.
6. Hire an assistant part time by the hour to begin to assimilate applications for credentialing,
hospitals, ASCs, etc. Pull together documents needed for the assistant to begin filling out the
forms. Such documents include:
a. CV with names,addresses, fax and telephone numbers of all current and former employers
and medical staff appointments,
b. All current and past state medical licenses/license numbers, effective date, status
c. UPIN number, current Medicare number
d. All current physician demographic data
e. Information regarding any malpractice suits including case number, all named parties, date
filed, disposition of case
f. Current completely legible copies of the DEA and state narcotics licenses, state medical
license, current license registration card (note: if legible copies are not sent, especially of
the DEA license, the applications will be rejected
g. Copies of your medical school diploma, undergrad diploma, residency completion
certificate, board certification certificates, FLEX or NMLE certificates
h. Complete addresses and telephone numbers of your undergrad college including the dean
or president at the time of your attendance, medical school (including name of the dean
during your time there), residency and internship including program directors name
The assistant should make at least 20 copies of each of the above documents and keep the copies
in individual files. See the chapter on credentialing for more information and on PHCS and CAQH.
7. Begin to evaluate potential staff who might be an appropriate match with your selected practice
model and your personality. Sometimes staff can be acquired from local hospitals, ASCs,
physician offices, etc. If you hire a part time person to help complete the endless forms, it is
possible they might be appropriate for long term employment. It is not necessary for the staff to
recognize they are being evaluated by you, but it may be useful to mention to potential candidates
that you are opening your own practice and when you plan to open for business.
5 months in advance
8. Acquire names of billing companies from other pain physicians. Do not make the mistake of
confusing a good anesthesiology or PM&R billing company with a good pain management billing
company. Unless the billing company is already doing a significant amount of pain management
billing, seek another company (See the chapter on billing later). If you currently have a pain billing
company doing a good job for you, it is acceptable to retain that same company for your new
practice. Interview at least 3 companies with a focus on the percentage of collections the company
charges, how many billing cycles prior to sending to collections, how patients are contacted when
they have due balances (a computer generated letter, a telephone call, or an attorney's letter),
whether the checks are received and deposited for you in a bank or whether your staff has to
provide this service, compliance program, whether billing company upcoding or downcoding is used,
patient balance availability (on line per patient is much better than paper), reports available, if a
specific person will be assigned to your claims, etc. Some billing companies tout a 95% collection
rate while others may collect 50%. The actual dollars collected may be the same but the accounting
methodology may be different.
Unless you want a huge headache, do not start a practice with in-house billing, even if using an
integrated EMR/billing program. The complexities and time required will rapidly overwhelm your
staff. Use an external billing service for at least 6-18 months until you can grow into in-house billing.
9. Begin viewing EMR programs via internet demonstrations or CDs of the products. Some EMR
will permit you to download a working copy to try out. If you find that program is not acceptable,
there will be no charge. The EMR should have the following components: input method consistent
with your capabilities (eg. if you can't type, don't acquire a keyboard input system), integrated
scheduling program, optional billing program which will seamlessly interface, capability for
expansion, built in fax capability or print to fax, off-site data backup, and any bells and whistles
needed. Some companies will lease the program while others require an outright purchase. For a
small practice, large programs do not work well since they are cumbersome and designed to run an
entire medical complex, not a small physician office practice. Many of the programs are scalable to
the practice size and many have either synchronization of laptops or VPN/remote access
capabilities. The ability to access the records 24 hours a day from anywhere has proven to be an
extremely valuable addition, especially when a patient of your practice is seen in an emergency
department at 3am and you do not want to travel to the office in order to have accurate records with
which to consult with the emergency physician. See the EMR chapter.
10. Check out potential facilities in which to perform pain management procedures. Those ASCs or
hospitals that perform a significant number of pain procedures are often set up for both low level
injections and intermediate level RF procedures. Specialty units such as pain management ASCs or
centers within a hospital may be far more efficient than a traditional OR and may afford advanced
procedure opportunities due to the availability of equipment. Obtain applications from the medical
staff offices of the hospitals or from the manager of the ASC. Find out from the hospital or ASC
which insurance plans are accepted and in which insurances they participate. There is nothing more
frustrating to a patient than to have an in network physician perform a procedure in an out of network
facility when an in-network facility was available to the physician. Often this results in hundreds to
thousands of dollars extra cost to the patient. Apply to the facilities and on requesting privileges, be
capable of demonstrating training and if possible, certification in the privilege requested.
4 months in advance
11. Peruse the Federal Employers Tax Guide Circular E and the Tax Guide for Small Business.
After viewing the documents above, you well may elect to have an accountant manage the tax
calculation and payments.
12. Contact your malpractice carrier and notify them of the change in practice location, change in
the type of practice, and what new techniques you will be performing. While it is usually possible for
a physician to remain with their current carrier, some insurers will place extreme restrictions on pain
management to the point some intermediate-advanced procedures (eg. intrathecal infusion pumps)
are no longer covered or are covered by at extreme malpractice insurance rates.
3 months in advance
13. If this is to be an independent office, seek office space. If not, then begin contract discussions
with another physician or entity to lease their office space. Avoid giving kickbacks to the surgeon by
settling on a fixed rate, not on a percentage of collections basis. Most pain management offices do
not need elaborate traffic management systems or large space acquisition. Usually a small
procedure room for on-site injections and an office in which to see patients is sufficient room to
begin with if the space is expandable. If not, consider a location that is expandable. Of course,
scheduling and front office secretarial space will be necessary. Don't build a Taj Mahal on your
initial encounter with an office based practice. It is not necessary. Remember to build in space for
file cabinets (if you use a paper system) and a large heavy safe bolted to the floor if you plan on
performing intrathecal pump refills in the office. Most pain physicians do not retain IV narcotics
such as morphine/meperidine on the premises due to the potential for theft of such, even if kept in a
safe.
14. Evaluate telephone systems. A 4 line portable telephone system works well for an initial office
design and can be used until that time 4 lines are insufficient, then a more advanced system
purchased. Rollover of lines is programmed by the telephone company off-site. A Panasonic
cordless 4 line system is less than $400. More advanced telephone systems typically cost
$1500-$4,000 therefore the Panasonic system is a good place to start. In order to avoid employee
cervical strain, inexpensive headsets plug into the cordless telephones. While the advanced
telephone systems are daunting in their capabilities, usually only a few of their features are used. A
local communications company will sell and service advanced telephone systems.
2 months in advance
15. Obtain signage for the practice location (permanent and temporary). Tasteful banners may be
created to announce the opening of the office, but may require city permits (with fees) in order to
display these. Planning and Zoning Commissions or Departments are the usual contacts within the
city government in order to obtain such permits which are time sensitive. The permanent signs on
your doors, windows, and exterior of the buildings may require approval of the landlord, corporate
association, city, etc.
16. Arrange to purchase insurance on the property to insure against injury on the premesis due to
patient falls, etc.
17. Contact local newspapers and radio stations for additional advertising. Alternatively, if you are
a referral practice only, then one may enter an advertisement for the opening of the practice in the
local newspapers. Sometimes, the local hospital where you are on staff will provide some
advertising in the form of a new-staff anouncement. Brochures, trifold, can be created on a word
document and printed in bulk by a local printer. These can be effective advertising tools when given
directly to a potential referring physician.
18. Call potential referring physicians individually to arrange to take them to dinner as a way to
introduce yourself and to display your wares.
19. Check out furniture possibilities for the office and order the furniture. That from Office Max or
other such supplier is excellent furniture to start a practice with. As the practice grows, more
elaborate furniture, expansive settings, and complex billing systems may be introduced.
1 month in advance
20. Electricity, gas, and water turned on if you are the person responsible for this (as opposed to a
shared cost between several other building members.
21. Hire staff to begin 1-2 weeks prior to the actual opening.
22. Arrange to acquire a credit card machine with smart card capabilities if credit cards are to be
accepted (strongly encouraged). Obtain a cash drawer for collecting copayments and deductables.
23. HIPAA and OSHA regulations implemented in the office, employees must have obligatory
training in such. Usually a minisession in these areas are sufficient.
24. Establish prescribing rules, written narcotics policies for both patients and staff, and office
operations policies prior to beginning seeing patients.
25. Order prescription pads (suggest duplicate pads only).
26. Establish patient initial encounter and followup forms.
When changing from one pain practice to another, some of the above will not apply since these
elements will already be in operation.