BarbaraNP

There are two videos that NPs in CA might be interested in on my channel. One in which Melanie talks about Independent Contracting in California, and one in which we talk about this new law. I'll try to post the links here. The other is also of note for those who are forming businesses as Independent Contractors. It's really important to understand the laws in each of our states, and also support our NP organizations.

When I last had a conversation with Melanie Balestra, NP, JD in California about this (recorded and is available on Youtube), the rules were still in the process of being written. It's definitely not FPA in terms of no physician involvement, but is a step, hopefully in the right direction. NPs in California will still have hoops to jump through, but it is doable.

DOT https://nationalregistry.fmcsa.dot.gov/NRPublicUI/home.seam

I cannot answer your question, but best of luck!

Agiboma, There are far too many variables to even begin to answer the question. What kind of practice? Where will you be located? What kind of patients will you see? What payers? Will you be direct pay? What kind of equipment will you need vs what you already have? What kind of assistance will you hire, outsource? Billers, software.... Factor in professional fees (atty, CPA, business adivsor, etc) Don't forget TAXES! There are regional differences in reimbursement, payroll, lease payments, insurance and so much more. Get start reading business blogs and books. There are blogs for nurses and nurse practitioners who want to be self-employed. There are groups on other social platforms devoted specifically to this. Do some homework in your area. There are NPs in business almost everywhere. Good luck, ~ Barbara

NYS has a lot of NP owned practices. I know in their conferences (state and regional) they address these issues as well, so make sure you get involved. Best wishes! ~ Barbara

Agiboma, Startup cost vary drastically. It depends on things such as location, type of practice you want to start, state rules (how many hoops must you jump through), equipment and more. It's imperative to sit down and do some research on business startup cost in your area as well as ongoing operating expenses. That said, I have worked with NPs who have started practices for less than $10K to over $250K. It just depends.

If you are working as an independent contractor, you ARE your own business. As an IC, you must pay your own taxes and your own benefits. Some consider it a gray area if you are not organized as an LLC or PC as opposed to being a sole proprietor (the later does not provide you with any protection in terms of your assets). As an LLC, you can elect "flow through taxation", which makes it somewhat similar to how you pay your taxes. In most cases, you are not paying more taxes, but will likely pay less taxes as you'll have several tax deductions you can take as a business owner (and yes, that does mean the IC). I hope this makes sense. It's easier for me to talk about rather than write about. BTW...if it looks like you might not be really be an IC, both you and the company that is using your service potentially could face fines with the IRS. BarbaraNP

As an NP who teaches others about having their own businesses and practices, I'd like to chime in here. While working as an RN (and later as an NP) being paid an hourly wage, or even when on salary, I never worried about the overhead cost of seeing patients. Now, as a practice owner, I understand the reality all too well that time truly does equal money. Unfortunately, not everyone understands this reality. Stop for a moment and consider the overhead (ie, cost to run the business) of any practice, hospital, community clinic. Overhead include (and are not limited to): lease/mortgage; salaries and taxes (often the highest/2nd highest expenditure); utilities (heat/air, water, sewer, garbage); phone and internet access; liability and business insurances; licenses; housekeeping; office supplies; medical supplies; lab costs, including those utilized for POC); billing personnel or billing service (quite high usually); professional services such as the CPA and attorney and a myriad of other costs...before the practice owner ever gets a dime. Now look at the other side of the equation: a practice owner only makes money when patients are seen (unless you are seeing pts under a capitated plan as was explained by dudette10). There are several ways to look at this: cost per patient, cost per day, break even points. For example, (using made up round numbers to make this easy). If the overhead cost per month is $5,000 (this would be a very small office), and your average reimbursement is $40.00 (it's often lower than this for Medicare/Medicaid), then the practice (and often the practice owner) does not make any money until 125 pts are seen that month. However, just because the patients are seen, does not guarantee that the practice will get paid. I am only half joking when I say that insurance companies are not in business to pay your claims. There are many more variables that go into this, but I write this to give an example of what every practice owner must consider. As nurses and nurse practitioners who are employed, we would do well to learn a bit about the business of healthcare. No one can provide services for free. Even if you volunteered your time entirely, someone has to pay for the cost of providing the service. There is no such thing as free health care. Period. Someone is paying. And as a professional, don't you deserve to be paid?

I believe they mean you can only prescribe the medication. You cannot dispense it from your office. BarbaraNP

Another thought...in your ANP program, you can do lots of gero. You can also focus on gero in your CE once you have your ANP. I agree that with an ANP you will be far more flexible. I started about as GNP and went back to get FNP. Not to work with kids (I don't), but because I wanted to work with adults of all ages, AND have flexibility. My practice now is adults, with a heavy load of gero. Keep in mind too...younger folks are being admitted to LTC...being an ANP will allow you to see some of the young ones. When I got interested in gero, my coworkers in critical care (where I had been for 15 yrs as CCRN) thought I had lost it and "failed". They could not be further from the truth. It takes great skill to be able to diagnosis and treat, problem solve and support patients, family and staff. The furture of GNPs is bright. You can work in LTC, Assisted Living, House call practices, and private offices to name a few. You can work for someone, or for yourself. The shortage in this specialty area is severe. If you enjoy gero...go for it. Don't mind your classmates...it's your work, you life. Do what gives you joy. HTH, BarbaraNP GNP 1988 FNP 1998

Of all the applications I ever had to do, Medicare was perhaps the most frustrating. It can take 90-120 days to get your Medicare #. The good news is that you begin to see patients and hold the bills until the numbers come through. BarbaraNP

Credentialing is going to be a bit different from state to state as far as who you can credential with and what their requirements are. I happen to believe we all should be billing under our OWN credentials and not the physicians. It's one of the things that keeps us invisible. Credentialing can be a pain. Often times there will be someone in the office to help, but if it's a small office there is going to be less help. CAQH is relatively easy. The info that you needed for them, is what you will need for everyone. In our state (WA), there is a state provider application we use for ALL insurances...I just make copies of the parts I can. Medicare and Medicaid are a bit different, but I'm sure that surprises no one. The basic info is the same however. It does take a while. I often advise NPs to start this ASAP when opening their own practices. Keep copies of EVERYTHNG and keep a spreadsheet of when things were sent, the person you need to contact, when you should be following up etc. Most of all...breathe. Best wishes, BarbaraNP

Check http://www.fhea.com and http://www.apea.com I took my exam so many years ago, I don't know what I studied. Sorry I couldn't give you more info. BarbaraNP

You may need to get legal assistance for your corporation documents depending on what is needed for your location. If you want to do it yourself, NOLO publishes several books on this. I'd also closely following Medicare's Home Health Agency center : http://www.cms.hhs.gov/center/hha.asp BarbaraNP

The Medicare contractor for Texas is: http://www.trailblazerhealth.com/. You may be able to find the rates you are looking for there. You will need to know CPT codes. For Medicaid, you should be able to find the fee schedule. Most state have them listed. You might also check LeaRae's website (http://www.Nurse-Entrepreneur-Network.com)...I believe there are a few RN's who own their own agencies there. Best wishes! BarbaraNP

Medicare and Medicaid Numbers are different from your NPI. Even if you are not applying for Medicare and Medicaid, you need to have a NPI number. You'll need it for everything else. Apply here for your NPI Number: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart BarbaraNP

I started as a GNP (certificate) and later went back to school for FNP. I much prefer adults and geriatrics. I have my own practice, a good percentage of my pts are geri and I also see pts in ALF's (all geri). BarbaraNP

The biggest things are: - Focused - Implementation - An open mind - Flexibility - Determined - Passionate about their business - Willing to invest in their business - Understands the value of a mentor - Truly understand the concept of win-win-win - Failure does not mean stop, it merely means "next"! BarbaraNP

Your questions is not stupid...but the answer is multi-factorial. There are several places to start out. Certainly SCORE and SBA can help you with doing research and how to start. As far as websites, it really depends on your idea, if you are looking at something local vs global, etc. Look at: location, demographics, who is buying and who isn't, what you can do that is different from everyone else out there (better service, better product, better presentation). You'll want to niche your idea down (you cannot serve everyone). Look at what it takes to start up and what your likely ROI will be. Again, unless you want to create a job (and you don't if you have read Kiyosaki's books, I highly recommend Michael Gerber's books and websites. There are only a few websites geared toward nurses in business that I am aware of. http://nurse-entrepreneur-network.com/ https://nnba.net/ I'd start with LeaRae (first website) as she has ongoing support for nurses in business. I also have a website, blog and consulting around business geared toward NPs. We often interview NPs (few times a month on Sundays) on business, and those are open to anyone who wants to listen. You'll likely find ideas here as well. Coming up will be an NP/CDE who does nutrition work. BarbaraNP

There are nurses/nurse practitioners around the country who have their own businesses. There is a lot to having a business, and one that supports you. 1. Figure out what you really want to do. 2. Do some research once you have a few ideas. Will it generate an income you can live with/you desire? Will it give you a lifestyle you desire? Is there a market for it? 3. Get use to the idea of talking about $$ and charging for your services. If you don't...you don't have a business. 4. Get some support. There are groups and websites that work with Nurse and Nurse Practitioner Entrepreneurs to help get you going and keep you going. It's hard (nearly impossible) to do this alone. 5. Start reading about business. Start with something like E-Myth by Michael Gerber. Learn about the laws for your location and where your license may/may not restrict you. Look at SCORE.ORG and the SBA.GOV. Best wishes, BarbaraNP ~ business owner

There are LOTS of NPs around the country that own their own practices. Rules and regs will vary from state to state. For example, in CA you cannot "own" the majority of your practice, it must be 51% physician owned. I'm in WA and own my practice without any physician ties. In states where you must have collaboration, NPs are able to "hire" a physician as a collaborator or consultant...again, it will vary with your state. If you search Nurse Practitioners and Business or Nurse Practitioners and Independnt or Private Pratice, you'll find resources that may help you. There are also a few books at Amazon...Carolyn Buppert is great for legal issues to consider, and Carolyn Zaumeyer wrote on Independent Practice. I have a blog on NPs in business as well. Best wishes to you! BarbaraNP

Contact a physician you have worked with, who might be of similar thought (ie holistic) and ask. You might also consider a Nurse Practitioner as they can give you standing orders as well. BarbaraNP

When I took a year long break from practice, the first thing I did was to get ahold of Ferri's Clinical Advisor. That's help jog my memory and make sure I was not overlooking something. I had it on my PDA. I would image that 5 Minute Clinical Consult is the same. BarbaraNP

NPs have been doing this for years. I became a GNP in 1988 (and later FNP) and that was my job for many years. I was hired by facilities to be onsite. The problem was...I could not bill for my services as I was employeed by the facility. Years later, I was hired into a private LLC group that was owned and operated by a hospital. We...2-3 GNP's and one MD covered 4-5 LTC facilities for most of the providers in the county. We had written agreements with all of them. The MD of our group was the Medical Director in almost all the buildings, and we, the GNP's were in various buildings on a daily basis. We were able to keep people out of the ER and out of the hospital. And because we were right there (and covered call 24/7) we developed great relationships with the nursing staff, did lots of teach, and helped the facilities increase their quality of care. What is really needed now, is to allow NPs to be the attendings in these facilities. BarbaraNP