When Nicole Ottens, D.O., joined Mattoon, Ill.’s Sarah Bush Lincoln Health Center in July 2010, setting up her practice was "incredibly easy," she recalls. As an emergency room physician employed by the 128-bed rural hospital, she didn’t have to make many decisions.
The hospital’s recruiter and human resources department processed the paperwork for securing her credentials. She didn’t have to market her services, because sooner or later people use the ER. And because she joined a department already staffed with nurses, she just became one of the team.
Ottens, who will soon be dual boarded in emergency and family medicine, was delighted with the process and even happier with her choice of employers. "All I want to do is to provide quality care to my patients," she says. "This is the perfect job and the perfect way to do that."
Perhaps you’re looking for the same streamlined experience. You want to sail through the formalities of launching a practice so you can just take care of patients. But establishing your practice is as important as anything you’ll do in medicine. It usually takes time, patience and attention to detail to make the smooth transition from training to your first job or from your first job to the next. To launch yourself as a skilled practitioner open for business, you’ll have to focus like a laser on key tasks: putting your credentials in order, marketing your name, staffing your office and equipping it too.
Are you in this alone? If you’re flying solo, you’ll have to take care of every aspect - unless, of course, you’ve already tapped a business manager. It’s the nature of being a lone wolf. But if you’re destined to join a group or hospital staff, you’ll likely have lots of guidelines, to-do lists and helping hands.
Organizations are usually quick to help physicians navigate a practice setup. Depending on the size, you’ll have plenty of assistance for mastering the terrain.
As Dorrie LeForce, director of operations for the Dallas-based HealthTexas Provider Network (HTPN), the 500-physician Baylor Health Care System-affiliated group, notes of their extensive soup-to-nuts assistance they give new hires: "We’re the legs and arms to support them in everything they need to open their doors."
You can’t treat patients unless you have proper credentials. It’s that simple. The first order of business in setting up your practice will be to get licensed by the state, affiliated with area hospitals and approved by Medicare, Medicaid and the major payers your employer wants to bill for your services.
Some fundamental items - such as NPI (National Provider Identifier) and DEA (Drug Enforcement Administration) numbers - you’ve likely already presented as part of your application. If not, you’ll need to apply for them before you can bill and prescribe drugs. Likewise, if you’re staying in the same state in which you trained, you already have your medical license. But if you’re moving to a new area, getting it will be a priority.
Once you have those basics, you can complete the paperwork for your group’s major payers and professional liability insurance. In terms of malpractice, you’ll likely have the same carrier and coverage as your colleagues in your specialty, but you’ll still have to apply separately. Educate yourself about the coverage limits, how any suit might be settled, and what happens with the tail.
Chances are very good that the group or hospital you’re joining will help you navigate the paper chase. Start dates are usually contractually contingent on having your ducks in a row so you can see and bill patients on day one. Most organizations have an office or function to handle the details and keep the process moving forward.
So what’s your responsibility?
• Make sure your information is complete. Leave no time span unaccounted for or stone unturned about your training and work history. A non-problem can become a problem if you answer "no" to a question that should be a "yes." Even if hiding something wasn’t your intent, it looks like your intent if you can’t account for holes in your CV or explain a dubious episode, especially involving complaints by patients.
"The most important thing is to be careful and clear," says Paul Sherman, M.D., MHA, associate medical director, strategic deployment, for the 1,200-member Seattle-based Group Health Physicians. "If you’re not sure, ask."
• Be a stickler for deadlines. Most new physicians know about their first job a year in advance, so there’s plenty of time to submit relevant documentation. But that means responding quickly to every request. Credentialing can take up to six months, depending on the number of applications you’re submitting and the organization’s policies for processing them.
At Group Health Physicians, for instance, the general credentialing and privileging committee isn’t the only panel to sign off on a new doctor. Members of the applicant’s specialty also get to review the file, making sure that the physician has performed enough of a given procedure to be privileged for it.
New physicians recruited by the Surgical Institute of South Dakota, P.C., in Sioux Falls may have to allow time to get a state medical license. Most recruits need to check licensing off the to-do list first. Practice administrators get the paperwork rolling in February or March so it’s completed by the candidate’s summer start date.
"You need to start early and be diligent about completing the paperwork," says Mark Hatting, CPA, CMPE, executive director of the six-physician general surgery practice. "The process can be laborious, boring and frustrating at times. But you have to be patient and accept all the help your administrative staff offers."
When he first left training, Chris P. Lupold, M.D., now a Strasburg, Pa., family physician, had no idea that he’d have to get credentialed with so many insurance companies. But the practice manager at the Charlottesville, Va., group he was joining at the time was extremely proactive in sending materials and keeping him focused. When Lupold joined Lancaster General Medical Group, a 100 - physician multispecialty practice, in 2008, the process slipped his mind until others reminded him two months prior to his start date. He had to play catch-up with the paperwork before joining his four colleagues at the Strasburg location.
His words to the wise: Take credentialing seriously. Know who’s in charge. Find out who will pay the costs. And keep copies of everything so documenting your past if you need to in the future is a cinch. For instance, because Lupold tracks his malpractice policies every year, when he had to provide proof of coverage back to residency, he was able to dip into his files. "It’s a lot easier than having to ask somebody else for it, especially if you’re leaving that practice."
Letting people know that you’re taking patients is the only way to build your practice. You’ll likely have access to marketing professionals ready to make your face, specialty and skills familiar to everyone. But what should you do to toot your own horn?
Depending on the organization’s media savvy, your biography should be fodder for anything from an internal mailer and external news release to a website and even Facebook page. Since Googling is second nature to many consumers these days, most practices include a web presence among their marketing tools. Make sure you review it.
When Lupold learned that some of his new patients found the practice via various insurance websites, he made sure that he updated his material every three months, especially when he became board certified.
Even with today’s communications gizmos, the single most effective tool in your marketing arsenal is word-of-mouth. If you’re not going out into the community, developing solid relationships with colleagues and interacting well with patients, all the advertising in the world won’t make a dent.
"If you don’t get out there, people don’t know that you exist," says Randy Buchnowski, chief operating officer, Physician Enterprises, the provider network affiliated with Centura Health, the Englewood, CO-based health provider. "They don’t know what sets you apart. What makes you different? What makes you special? That’s what you need to tell others."
Whether you’re a specialist or primary care physician, meeting doctors and other health providers in their environments not only adds to your credibility with patients when you need to refer them, but can reap rewards for you, too.
As one of more than 200 orthopedists in the Dallas-Fort Worth metroplex, J. Scott Quinby, M.D., now co-director of Baylor SportsCare, head of the division of orthopedics, Baylor Medical Center at Uptown, learned early on that competition would be pretty fierce. He had to gain the trust of as many primary care doctors as possible so they’d refer their orthopedic patients to him. Quinby was persistent in knocking on doors, visiting clinics and giving orthopedic lectures to primary care colleagues, all of which "helped out tremendously."
"The main thing, especially from a specialist’s standpoint, is that you must aggressively market yourself," he says. "I’ve seen people fail because they just sat back and waited for others to help them. But you can’t depend on somebody else to do it. You have to be very assertive."
When Luis Perez, D.O., opened his family physician office in Vermillion, Ohio, this past summer, he knew the territory. Because he had trained within the same system that now employs him - the Firelands Physician Group, a multispecialty entity affiliated with Sandusky-based Firelands Regional Medical Center - his name rang a bell. People who knew him recommended him to their acquaintances. Because he’s the only doctor in this office, however, he’s still doing his part to raise his community profile by giving speeches, doing interviews and helping with the local triathlon.
"Doctors shouldn’t be too bashful," Perez says. "People have a better idea of what you’re like if they actually meet you in person or hear you speak at an event rather than just seeing your photo in the paper. Sometimes it’s a little intimidating to do those things, but I think it’s worthwhile."
The people surrounding you will be instrumental in making your day flow seamlessly and your patients confident in your abilities. But how much input will you have on those decisions?
You’ll likely have no say in hiring administrative and support employees such as billing clerks or lab techs since they’re part of the general office staff. But you should have a big say in the choice of any clinical employees - your nurse, nurse practitioner, medical or physician’s assistant or other ancillary provider - you’ll oversee on a day-to-day basis. If you’re replacing another doctor, you may have to learn to work with the existing staff. But if your hiring means the department is expanding, you’ll probably be involved in those choices.
Perhaps you won’t sit in on the initial interviews. Practice managers or human resource departments usually screen potential employees before presenting acceptable candidates for final interviews. (They’ll also determine the salary and benefits package, based on tightly defined compensation policies.) But most organizations will encourage physicians to participate in the final interviews. Some doctors would rather leave the decision-making to the pros. Yet it’s probably a good idea to participate, even if you have to do it via a conference call.
You want to find true peers in terms of your personality, patient philosophy and work style.
When Perez set up his Vermillion practice, administrators made filling his staffing needs a breeze. Because his office was part of the larger Sandusky multispecialty group, he had access to people with significant experience in recommending the professionals he would need.
Perez never worried that his wishes would be ignored. The group’s clinical practice coordinator was open to his suggestions, including taking names of nurses who had already expressed interest in working with him during his training days. In the end, administrators prescreened several good candidates for his nurse and receptionist positions, letting him conduct the final interviews before making his choice.
"I was actually very involved in choosing the staff," he says. "I was very grateful for that. These were the people I would be working with daily, so the personalities had to mesh. We had to make sure that we were a good fit for each other."
Whatever your personality, make sure you understand the organization’s clinical staffing pattern as early as your own job interview. What’s the philosophy about RNs versus LPNs, or nurse practitioners versus physician assistants? If your volume grows, can you increase your clinical support staff? Will you have your own medical assistant or must you share with colleagues?
Your employer may not operate under a traditional one nurse/one doctor model. Instead, nurses may rotate among the physicians with medical assistants teaming up to cross-cover phone calls and "room" patients for several doctors.
When Lupold joined the other four physicians at his Strasburg, Pa., location, he not only inherited the current nursing staff, but also a work model that has him interfacing with several nurses throughout the day. Rather than being assigned to specific physicians, they rotate among the medical staff for half-day or longer segments. Admittedly, the nurses don’t get to know each practitioner quite as well as they would if they had a one-on-one relationship. Yet if one of them is absent, others can easily fill in because they’re already familiar with the doctor. Although Lupold likes the structure, he warns that it may not be for everyone.
"If you’re the type of person who wants to get to know one or two nurses really well, rather than knowing everyone a little bit, this may not work for you," he says. "You need to ask, ’Does it fit my personality? Is it the way I want to practice?’"
Choosing the right tools is an essential step in setting up every practice. Whatever your specialty, you’ll need both business and medical equipment to work efficiently with co-workers and patients.
Most organizations have a person or persons to analyze and meet new hire needs. At Centura Health, for instance, the director of physician and practice integration, Jennifer Fritschler, is in touch with new doctors even before their office space is identified. She works hand-in-hand with them to ensure that every item - from floor plan to furniture - is in place on day one. Fritschler’s goal is to give providers a seamless start within the confines of a budget. "I make sure that everything that needs to happen happens," she says, "so they’re able to practice the way they want to practice."
So how much flexibility do you have in getting the equipment you need and prefer? Administrators will likely supply a basic business and medical technology package. You may get to pick the laptop computer or cell phone that works best for you while other items, such as automated blood pressure cuffs or EKGs, are standardized.
As to bigger-ticket items, your request has to fit the organization’s purchasing guidelines and budgetary cycle. If you’re introducing a new service, you may have more say, especially if the equipment is critical for taking care of patients. Even then, expect administrators to look carefully at a number of factors - clinical efficacy, potential payer reimbursement and return on investment - before signing off on the purchase. You’ll likely be told how much volume and revenue you’ll have to generate to support the investment.
"Certainly express your desires," says Centura Health’s Buchnowski. "It doesn’t hurt to ask, but be ready to hear, "’How about we wait on that?’"
For instance, when a new vascular surgeon recently joined Greensburg, Pa.-based health system Excela Health, administrators saw an opportunity to offer minimally invasive thoracic surgical procedures, given her skills. Because they had to acquire specialized equipment, however, they formulated a plan with the doctor that had some technology in place on her first day of work. Other purchases were postponed until the next capital expenditure cycle. The delay not only gave her a chance to establish her basic services, but also to gauge how the practice was evolving. "It really takes cooperation," says Kirk Miller, Excela Health’s vice president of physician services. "One size doesn’t fit all."
When Perez joined his Vermillion practice, he admits to a long equipment wish list. But after managers laid out his patient volume projections along with advice on what he should delay, he agreed he didn’t need everything until his census grew. So he negotiated the tools to evaluate such ailments as respiratory and ear complaints, but held off on the technology to assess other issues, such as diabetes.
"It’s exciting to have an office stocked full of great equipment, but if you don’t have the patient volume, it’s a liability," says Perez. "The better idea is to hold off with expensive equipment until your volume increases to the point where it can generate revenue."
Whether you’re new to your position or just changing jobs, you’ll have many other tasks to consider in setting up your practice.
If you’re coming out of residency or fellowship, you’ll likely have to adjust to the pace of private practice. Sticking to the schedule often challenges new doctors, especially if they don’t have many patients during those early practice-building months. It’s easy to let a 20-minute session go 30 minutes or more because you simply have the time. But as the schedule fills, you must quicken the pace since you don’t want to keep patients waiting.
Don’t be afraid to ask administrators, nurses or other experienced co-workers how to be an efficient, effective provider. In fact, it’s a good idea to seek regular feedback, especially to avert the kind of glitches that commonly occur.
One final thought: The success of your practice still depends on you. No matter what your employment structure, you’re responsible for making sure your patients’ needs are met. As Sherman notes: "Even if you’re joining a large multispecialty group, you have to realize that you’re the leader of the team. You set the tone, the pace, the collegiality and the expectations for patient-centered care."
Chris Hinz is a Milwaukee-based independent journalist who focuses on health care topics.