WEST SIDE EYE SURGERY

How to Start a Solo Practice

1. Business Plan

    It all starts here. You must be prepared to articulate your long-term goals and quantify your anticipated start-up costs, expenses and revenue. How will you support yourself and family before the revenue stream begins? Will you finance with investors or banks? Who will send you patients? How many? How much will an office visit and procedure generate? How much surgery will you perform? The little green book can serve as a good basic reference for starting a practice.

Link – spreadsheet.

2. Accountant – Incorporate

    Even if you’re a sole proprietor, your tax liability must be ascribed to your business and not to your personal wealth. Your accountant can help set-up the business and tax identification numbers. As a medical practice, the subchapter S designation for a PC, personal corporation is appropriate. Keep a log-book of your major corporate activity.

3. Insurance Agent/Disability

    Nothing happens without disability insurance. When asking for a bank loan, the financiers will demand proof that loan can be paid, even if you become disabled. Group disability can be had through the American Academy of Ophthalmology (Marsh Insurance Co.) and private vendors. For an individual, more than one disability policy may be needed to carry the business overhead, personal and household expenses. Expect the application and approval period to take several months. So get the process moving early.

    Ask around for an experienced insurance agent. You’ll soon need - Life/Key Man Insurance – insurance for the site & equipment and to protect yourself and premises against construction related miss-haps and other catastrophes.

4. National Provider Numbers

    The application is made on-line and takes a few days. You need two numbers: one is your personal number; the second is for your business. All submitted insurance claims will require these numbers.

5. Malpractice Insurance –

    Can be had quickly but must be in place before you apply for inclusion in health plans such as Medicare. Ophthalmic surgeons pay about $25,000/year – in quarterly payments.

6. Medicare provider number

      Use form 855i to apply. You’ll need two applications – one for your personal Medicare number and a second form for your new business. The personal Medicare number is tied to your personal NPI. The Business NPI is tied to the corporate Medicare provider number. Your billing will reflect care as a personal rendering physician but with pay-through to your business.

7. Financing Banks & Small Business Administration (SBA)

    Don’t feel obligated to try only one vendor. A reduction of one percentage point of interest will reduce your costs by $1,000/month on a 1 million dollar loan.   The SBA loan can be used for construction and equipment. Some banks may offer partial financing through the SBA and a line of working capital through the banking establishment. Consider the terms: you don’t want to place your home as collateral; SBA might demand it. SBA loans require little or no payment in the first year – and competitive rates over the next seven. Loans rates are set with a benchmark of the prime rate plus some extra percentage above. Try to get a rate as close to the prime rate as possible.

8. Electronic Medical Records & Practice management program

    The giants NextGen and Compu-link charge about $50K for software, installation, training and licenses and expect to pay another 10-15K for hardware (computers and servers. On top of that, the monthly fee is $350-400/month. They offer robust packages but getting the programs tailored to your practice may take lots of time and effort.

    MDOffice offers a good product at 2/3rds the price.

    Most EMR systems provide up-links from office - imaging equipment and analyzers. Look for lensometers, auto-refractors, perimeters, cameras and OCT with digital download features. 3-D OCT machines generate too much data for conventional EMR systems. Consider a second date server storage system if your future needs require state-of-the-art OCT imagery. Topcon’s EyeRoute system can store digitized images from OCT, cameras and visual field analyzers.

    All useful systems require an in-house server to maintain the files. You’ll also need to contract an IT guy to help install and maintain the system. The servers produce a lot of heat and are a little noisy. Consider placing a separate 12,000 BTU air-conditioner for local temperature control.

9. Leasing space

    Learn about the prevailing rates. Leases can be had for 5, 10 or 15 years. Most leases will include a clause for escalated payment over time. Ask for free rent for six months – time to get your office renovated and working before the bills come due.

10. CAQH & Enrolling in health plans

    CAQH (www.caqh.org) provides a public listing of your license, provider numbers, malpractice insurance, locations and all necessary data required by HMOs to register you as a provider. You have control over the record. Consider enrolling in many of the local plans at your start-up to help build a patient base. Patients will be able to find you as a local “provider.” Enrollment in individual HMOs may take months.

11. Hiring an architect

     Expect to pay about $50-$100/square foot of the space that needs renovation. The architect’s proposal will include: scope of work (measuring the space, complete architectural plans and specifications - with millwork and selection of furnishings, preparation of documents for building approvals and permits and certification that construction has been completed to the building code. Get references – and oversee the whole process so that the design works for you. Key items: sufficient waiting room space, handicap access, heating and air-conditioning and finishes. Today’s office is wired for computer networks, phones and electronic medical records.
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12. Hiring a contractor –

    Complete renovations cost about $1000/square foot. I had 5 contractors price renovation of a 2000 sq. ft. medical space – the bids varied from $150,000 to $409,000 with no major distinction in the overall project. Good finish work (plastering, painting and detail) and millwork are expensive – so is union labor. Ask to see the contractor’s work; get references. Good cabinets (suitable for a medical office) and countertops can be ordered through Home Depot. Write a contract so that the contractor gets paid after completing the work in stages – with 10% held back until the job is completed and all building department approvals are obtained. For example, the five stages may include: demolition, rough walls and carpentry, electrical and plumbing, painting, flooring and finishes, and punch list and sign-offs. And put in a penalty clause, e.g., $1000/day, to keep the project “on-time.”

    Make sure to address heating and cooling issues so you can maintain a comfortable working environment in all seasons. In-house servers generate substantial heat (and a constant low drone.) Consider placing them in a well-ventilated closet with a separate cooling system

13. Information technology (IT) man

    Your architect or contractor may provide a reference. Today’s modern office requires lots of networks, for diagnostic equipment, practice management computers and phones. You’ll want to put in the networks early in the construction/renovation process – well before the walls and ceilings are finished. If you install an electronic medical record/practice management system, you’ll probably need a large cabinet for a computer server.

14. Equipment

    A fully equipped ophthalmic lane costs $30,000, and can leased at about $500/month expense with purchase over five years. Equipment for a fully equipped office with four lanes, perimeter, laser, OCT and camera and laser can cost almost $400,000. Consider what you need to get started and what you’ll need for the future. Big-ticket items can often be had below the “retail” price. Don’t be afraid to haggle.

Further reading:

John Pinto’s Little Green Book of Ophthalmology (2005)

Published by the American Society of Ophthalmic Administrators
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