Psychiatric NPs or CNS/ starting a practice

Editorial Team / Admin · Aug 23, 2005

I am starting grad school to become a psychiatric mental health nurse When I am done I will be qualified to sit for my license as both an NP and a CNS. I want to know if anyone out there has started their own practice, how they financed it, if they worked while building the practice, and if they went in with another nurse and shared a practice. Also, how often do you need supervision when you are prescribing medications? What do you need to do to be able to accept insurance. Also if people know good websites that have the kind of info I am looking for please let me know. Also if I decide to work at a facility somewhere, (I live in MA and both CNS and NPS have prescriptive rights), which licensure should I get if I am interested in doing as much patient care as possible (more therapy type stuff) also what kind of facility is best if I don't want to become a prescribing machine. Thanks for the help.. I am really confused because I am new to nursing, and I am doing a masters entry program so I am not currently an RN. I just don't know much about the nursing world and how it works, although I have learned allot from reading these forums! Thanks again, please respond!!!!!!!!

I am an OB-GYN NP and for a very short while, had a practice in OB. This proved most difficult due to the liability issues. Too expensive to pay overhead, mapractice insurance, etc. I then became FNP and this has been a much more marketable career choice.

I then worked in the hospital and finally in a combined practice with 5 physicians. This proved much more profitable. The physician does not need to supervise in my state. You will need to see what the BON rules/regs are for your state. Some states do not require physician collaboration. Mine does.

The CNS and NP careers are interchangeable, but, the NP does more "patient care" in my state.

BCzito · Aug 23, 2005

I am an OB-GYN NP and for a very short while, had a practice in OB. This proved most difficult due to the liability issues. Too expensive to pay overhead, mapractice insurance, etc. I then became FNP and this has been a much more marketable career choice.
I then worked in the hospital and finally in a combined practice with 5 physicians. This proved much more profitable. The physician does not need to supervise in my state. You will need to see what the BON rules/regs are for your state. Some states do not require physician collaboration. Mine does.
The CNS and NP careers are interchangeable, but, the NP does more "patient care" in my state.

Yeah I know if I open a place of my own I would need to be supervised on medications once every three months. The think I worry about is, if I can take insurance and how to go about that, also what is a range of malpractice costs I have no idea about what type of cost I would be talking about here. I live in Boston so I think there is a high potential for getting clients, but I don't know about that if I only offer on a cash basis. I would like to be able to take insurance, but I don't know how that works. I really want to do psych work, but I am afraid if I work in a hospital I will become a prescription writing machine, and won't really get to do any therapy with patients, hence being so concerned about starting a practice. Also what are you referering to concerning "overhead" do you mean start up prices? Thanks for answering, its a long confusing road starting out on this path...!

Editorial Team / Admin · Aug 23, 2005

Yeah I know if I open a place of my own I would need to be supervised on medications once every three months. The think I worry about is, if I can take insurance and how to go about that, also what is a range of malpractice costs I have no idea about what type of cost I would be talking about here. I live in Boston so I think there is a high potential for getting clients, but I don't know about that if I only offer on a cash basis. I would like to be able to take insurance, but I don't know how that works. I really want to do psych work, but I am afraid if I work in a hospital I will become a prescription writing machine, and won't really get to do any therapy with patients, hence being so concerned about starting a practice. Also what are you referering to concerning "overhead" do you mean start up prices? Thanks for answering, its a long confusing road starting out on this path...!

You are welcome. :balloons:

Some insurance companies will not recognize the NP/CNS. You would find out through trial and error if you do not investigate, especially, the more common ones utilized in your area.

I am not a "prescription writing machine". I most definitely treat the person with meds if needed, but, do not totally rely totally on that. I have seen many NPs with the same concerns. I do not have a problem with the word "NO" if it is not necessary.

Overhead. The expense of running a solo/combined practice. Paying the rent, utilities, salaries, insurance, etc.

Hopefully more interested parties will respond to this thread and give you their idea/opinions, too. :)

ECMOismygame · Sep 3, 2005

...........

BladderCancerSxMgt · Sep 3, 2005

Here's a book I found useful in learning about the basics. It's written by a psych CNS in CA.

http://www.amazon.com/exec/obidos/tg/detail/-/0826194400/qid=1125718308/sr=1-1/ref=sr_1_1/103-5473150-4980650?v=glance&s=books

BCzito · Sep 3, 2005

you are thinking of working as a RN before NP right???????????

Well its a 2 year program, I already have a bachelors in behavioral neuroscience. Once I start the program, it will take about 8 months before I am an RN (its an accelerated program) and then I will be working as a nurse in my specialty during the entire second year during my clinicals. I am not sure if I will decide to get a job as an NP immediately or take an RN job. I will already have the experience of what types of responsibilities and what types of stressors that staff nurses experience on the job. I think it will all depend on my confindence level once I graduate from my program.

Danielle

Vance · Sep 20, 2005

Contract Negotiation for Nurse Practitioners

4. Negotiating Compensation

Determining Worth of Service: When negotiating contracts, it is important to determine both the amount of income that the nurse practitioner may bring into the practice and the associated cost to the practice. While there will be variability among practices due to the specialty, the location and the outstanding debts of the practice, the following guidelines will help you determine what compensation you might be able to contract. The federal government focuses on three elements when determining compensation for medical services provided: cost of service (the cost of compensating the clinician providing the service); the practice overhead (includes utilities, rent, supplies, payment to support staff etc); malpractice insurance. While the formula used for Medicare reimbursement has been based on a percentage of 48% service, 48% overhead and 4% malpractice insurance, these percentages may vary from practice to practice. (See attached example from one primary care practice)

a. Ask for the percentage of practice income that goes for overhead expenses. Be sure to ask what the practice includes in the category of "overhead" expenses.

b. Generally a private practice will wish to net some profit from you participation. A general figure is 15-20%. Determine if that is the case in the practice you are considering. Is this included in the overhead cost quoted to you?

c. Determine if a percentage of your gross receipts are expected to be used for physician consultation. (Seasoned nurse practitioners may expect to pay 10-15% of their gross receipts for this service.) Is it included in the overhead cost quoted to you?

d. It will be important to be able to access your productivity data within the practice. Determine how this will be accomplished in the practice site you are considering.

DETERMINING ARNP WORTH OF SERVICE

The data in this example was provided by a nurse practitioner employed in an internal medicine practice in a small city in Kentucky. The income projected is based on the amount actually received by the practice for the nurse practitioner visits. Twenty five percent of the patients have Medicare; 65% have a HMO or PPO; and 10% have commercial insurance. The nurse practitioner saw 18 patients per day. Two were new patients; sixteen were established patients. Of the established patients, two were Level 2 visits, seven were Level 3, three were Level 4, and four were annual physicals (Level 5). There were also charges for two EKGs and three microscopic

urinalyses. The nurse practitioner generated income of $1075 per day - $5375 per week - and $258,000 per year (assuming 48 weeks worked).

The following chart illustrates the costs incurred by the internal medicine practice to employ the ARNP. Overhead costs include additional supplies and equipment needed, plus two full-time employees at $10 per hour to support the nurse practitioner (a nursing assistant and clerical help).

COST TO PRACTICE TO EMPLOY ARNP

Salary $80,000

FICA 6,120

Health Insurance 4,000

Malpractice Insurance 504

Continuing Education 2,000

401K 3,200

Professional org/license 150

95,974

Overhead 54,446

Expense to Practice 150,420

Income Generated by ARNP 258,000

Profit to Practice $107,580

Patient Care/Practice Expectations

a. Determine the number of patients the nurse practitioner is expected to see, remembering that a new graduate will need more time in the first six months of practice. It will also help to find out what the most frequently billed CPT codes are for the practice and the amount received for those codes.

b. If you are expected to take call or make hospital rounds, determine what percent of the other practice provider's salaries are attributed to this activity. You would expect to receive a like percentage if you take rotation with other providers. c. If you are to be salaried and your clinical and administrative schedule requires longer days or evening hours, you may wish to negotiate a half-day off/week to compensate for this time.

BONUS/PRODUCTIVITY/PAYMENT

a. Negotiating a bonus payment system may be important, particularly as the nurse practitioner develops a large patient base. Bonus formulas can be based on productivity, quality, profit or patient satisfaction. if a patient satisfaction based formula is agreed upon, using a satisfaction tool is helpful in determining the bonus formula.

b. A productivity-based bonus may be appropriate if the nurse practitioner is on at least a 50% fee-for service system. Formulas are usually based on number of patient visits per year. Quality based bonus payments may be more practical under a capitated system where profit is measured by maintaining high quality care in as few visits as possible. In this case bonuses should be awarded for meeting or exceeding quality standards. Profit Sharing

When negotiating profit sharing, it is important that the language regarding the determination of the profit share is clear. It is important to negotiate the right to access the company audit and a method for handling disputes.

5. Benefit Negotiations

The following benefits as a salaried employee should be included:

a. Health Insurance. Health insurance is an ever-rising cost of business. If you need family coverage make sure that it is a part of your benefits, even if you would have to pay the additional costs. Some employers also have dental and eye coverage for their employees.

b. Vacation. Vacation benefits should include at least three to four weeks a year.

c. Sick Leave. Sick leave is generally two weeks or one day per month per year.

d. Travel. Ask about travel allowance if house calls or travel to other clinics is

expected.

e. Continuing Education. Continuing education allowance and paid leave (one to two conferences per year is not inappropriate; be sure to include enough in

allowances to allow for airfare, room and food for at least one national

conference. (An allowance of $1500 to $2500 for this purpose is not

unreasonable.)

f. Malpractice Insurance. With malpractice insurance coverage, ask if it is an

occurrence or claims made type of policy and ask the amount of coverage.

Negotiate for a malpractice policy that is an occurrence policy for at least $1

million per claim and $3 million aggregate.

g. Fees. Membership in professional organization; licensure, and DEA fees should be paid.

h. Subscriptions. Office subscription to appropriate nurse practitioner journal.

i. Retirement Plans. Retirement plans including employer's contribution and years when vested needs to be determined.

j. Disability Insurance. Disability insurance is a benefit you may want to negotiate, especially if you are the major income producer in your family.

6. Contract Restrictions

a. Some employment contracts include a clause regarding restrictions on

competition. A restrictive covenant restricts an employee from setting up a

practice within a specified geographic area for a specified number of years. After leaving the practice the concerns of losing business if an NP moves to another practice nearby has made this inclusion a greater demand.

1.) Restrictive covenants are considered legal and can be enforced as long as they are reasonable. If this covenant is challenged in a court of law, the judge will determine the outcome. The judge will consider the needs of the public versus the harm to the employer.

2.) The restrictive covenant may be a fact of life, so decide if this is an area that as a NP you may be willing to give up realizing that you may have to trade-off other practice opportunities in order to get a reasonable contract.

b. A contract may include language regarding termination clauses. A contract may list specific reasons for termination with cause such as should the NP become disable, lose their license, be convicted of a felony, etc. A termination without cause contract doesn't give the NP any job security and is not considered prudent for a NP.

c. Avoid contract that include clauses that give the employer or contractor the right to make modifications at their discretion without notice.

d. Avoid contracts that do not have renewal clauses.

e. A lawyer knowledgeable in contract law should be consulted.

Authored by American Academy of Nurse Practitioners Committee on Practice: Chair, Margaret Friel, Staff Liaison,

Jan Towers, Lenore Resick, Mary Jo Goolsby, Evelyn Jackson, Norann Planchock, Sue Tanner, Barbara Weis

spilmaz · Aug 18, 2012

I did a ton of research so I thought this might help, bullet points:

1- AIA credentialing in NJ charges 160 for new apps and 40 to update addresses for your new practice location. If you credential with 12 insurances youll have no problem getting new patients

2- get an office in a building, with its own secretary and take your own payments, get Square on the iphone or get a credit card machine and dont take checks, theyre not worth the hassle. You can rent a new office for 150$ a month once a week to start then 500$ a month for a deidcated office

3- use free EMR, practicefusion.com being the easiest and do your billing with kareo which is anywhere from 69$ a month to 300 a month, well worth it

4- for pysch, you need a desk, computer and 2 chairs, literally, thats it

good luck

I saw call a few psychiatrists, they always have open offices and say you will give 25% to overhead, that is fair, and they will make a little and cover their own expenses for very little extra work if you dont want to take any risk