Starting own NP practice

Cool Nurse, BSN, RN · Apr 17, 2018

Hi, thanks for the great post. It's been almost a year since you posted this, if you could please give us an update on how your business is doing, that would be awesome.

maxdog · Jun 25, 2018

I called Bank of America because I saw their program for starting medical clinics. They mean MEDICAL clinics. Because I am an NP, they wouldn't even talk to me. I did get a loan, however, by contacting the Small Business Administration. $25,000 was approved with no collateral. My clinic is opening July 5, 2017!

I am opening my own practice here in Tennessee and Bank of America DOES NOT loan to nurse practitioners, anywhere in the US. They are the worst! I am actually going to close my savings account with them now. Wells Fargo met with me in person, however. They offer NP healthcare financing loans for amounts greater than $100,000, up to a term of 10 years, fixed rates. You need to show your last 2 years of tax returns, your projected first year of business income, current personal financial statements, and resume.

Tzi-tucson · Jul 10, 2018

I'm in Tucson also and wanting to start my own practice. What advice can you offer?

Oldmahubbard · Jul 10, 2018

I'm not sure whether it's permissible to endorse a book on this site, but here goes.
Take a look at Carolyn Buppert's "Nurse Practitioner's Business Practice and Legal Guide".

Sadly, this is a kindergarten view IMO. All very, very basic, and common sense info. Not much real help in starting a practice.

Insurance companies will not reimburse you without a collaborator, I don't care where you live.

lovely30 · Mar 4, 2019

Hi there! I’ve been NP for 8 years and now I want to have my own. I found this post and love all who responded. I’m just curious, I know this varies but what is the net income for NP private practice annually? Esp in Wa states. I’ve been looking online but can’t find any info. I want to know if it’s worth for me. I’m leaning more towards house calls. Thank you!

ToFNPandBeyond · Mar 7, 2019

On 5/8/2017 at 12:42 PM, pattifnp said:
I interviewed a few EHR vendors... I'm using PrognoCIS, they have been extremely helpful with credentialing, set up, and cost. I gave them my information and they ran with it.
I have learned a few things I will share with you. No point in reinventing the wheel.
Please read your local law/state statutes etc. But this is my experience.
1. You need Employer ID. I did this with legalzoom, cost around $450 but they did the ground work and sent me in the right direction. You might look on line for info how to do this yourself. With this you establish your clinic as PLLC - professional limited liability company - ask your attorney or accountant which is the best way to handle your tax structure.
2. You need a registered agent. Legalzoom did this for me too, was included with the above fee. The way I understand this, the registered agent keeps track of where you are so that if there is any legal information that needs to get to you, they will find you.
3. Credentialing:
a. Practice NPI - this takes 2 minutes on line, you need your office address, phone number etc
b. Malpractice - this was more difficult than I thought because you will need a collaborating physician even if you are in a state that doesn't require it. (truthfully I didn't look into this very much because I'm in a state that does require collaborating physician) You don't want to pay your CP's malpractice, so if you have a CP, you need his/her Certificate of insurance. I used proliability.com for my malpractice, they were very helpful and included liability.
c. EIN (employer ID or tax ID) this is from the feds - as I said above I got it from LegalZoom
d. My state board of nursing had to write a letter to verify that I am a registered nurse and legally able to provide nursing services
e. Articles of organization: this came from the secretary of state in my state - LegalZoom helped get this in place too. (Their fee was really reasonable since they laid the path for me.
f. personal NPI
g. CAQH ID and password
h. Medicaid ID and password if your state has it on line
4. Loan: You need to write a business plan. This is a MUST. When you do your business plan, you will think of a ton of things you need, want and this will not only keep you organized it will help you with your financing.
The bank will want your EIN, articles of organization and probably a letter from your state board of nursing. You may have to have your collaborating physician sign on the loan, not as an owner, but just that he/she is in fact, your collaborating physician. This bothered me a little, but I didn't have trouble getting a signature. Your loan expectations should be realistic. Look for office space, think about utilities, supplies, rent, EHR (around $600/month should get you started) Remember that you probably won't be paid by insurance for a few months, so give yourself plenty of time. You can go to the Small Business Association - look on line and you will find that you can get $25,000 without collateral, banks will contact you when you sign up. I applied at a local bank tried to get $50,000 for start up to pay expenses but they wanted me to put my house up as collateral... it was too scary, so I used recommended lender from SBA and got $25,000 within a couple of weeks.
5. Business bank account - Open an account as soon as you can put money into it. Usually need $100 to open the account, but you'll be glad you did. When you pay for things like EHR and for Medicare credentialing, you bank account NAME (name on your checks) must exactly match the EIN so than Medicare will pay you.
6. The EHRs I interviewed - you can find them on line - everyone has their own ideas about how they like their data managed. PrognoCIS, Athena, MediTouch, DrCHrono are the ones I worked with. I ended up with PrognoCIS because they took care of a lot of details for me.
7. Building, utilities: I just signed my lease last weekend. I have the keys!!! The building is empty, need chairs, tables ... exam tables are expensive, but there are some deals on eBay, and look on line for some medical discount places. I'm starting with the bare bones. When you sign up for phone, elect etc. you will need your EIN number here, too.
8. Your bank can help you with credit cards. My bank also has some HR services available, they will write paychecks, have insurance services etc.. it's a bit pricey .. but you can look for services you want to provide to your staff.
9. HR - you need CMS compliance forms - I just learned about this today from the malpractice guy, he is going to send me the paperwork for that. Also need worker's comp insurance and the signage to be in compliance with labor laws. This is on line too.
Make a list of everything you need. It's like playing chess. Moving one piece forward while you wait on others... then you proceed with the next layer...
I made a note book - keeping original documents in there, plus I scanned them into files in my computer. Just keep checking off your list. There's a lit of pieces but you can do it if you keep organized! I am working full time,, just finished my DNP (full time program) and have been setting up this clinic in my spare time...
GO NURSES!! FREE the NPs!! I wish the collaborating practice obstacle would go away from credentialing, financing and malpractice. (I think I forgot to mention.. Insurance companies will not pay you unless you have a collaborating physician, even if you live a state that doesn't require it) UGH!
FREE the NPs!!
Best of luck!

Amazing post!

DelanaRN, MSN, APRN, NP · Mar 28, 2019

On 5/8/2017 at 3:42 PM, pattifnp said:
I interviewed a few EHR vendors... I'm using PrognoCIS, they have been extremely helpful with credentialing, set up, and cost. I gave them my information and they ran with it.
I have learned a few things I will share with you. No point in reinventing the wheel.
Please read your local law/state statutes etc. But this is my experience.
1. You need Employer ID. I did this with legalzoom, cost around $450 but they did the ground work and sent me in the right direction. You might look on line for info how to do this yourself. With this you establish your clinic as PLLC - professional limited liability company - ask your attorney or accountant which is the best way to handle your tax structure.
2. You need a registered agent. Legalzoom did this for me too, was included with the above fee. The way I understand this, the registered agent keeps track of where you are so that if there is any legal information that needs to get to you, they will find you.
3. Credentialing:
a. Practice NPI - this takes 2 minutes on line, you need your office address, phone number etc
b. Malpractice - this was more difficult than I thought because you will need a collaborating physician even if you are in a state that doesn't require it. (truthfully I didn't look into this very much because I'm in a state that does require collaborating physician) You don't want to pay your CP's malpractice, so if you have a CP, you need his/her Certificate of insurance. I used proliability.com for my malpractice, they were very helpful and included liability.
c. EIN (employer ID or tax ID) this is from the feds - as I said above I got it from LegalZoom
d. My state board of nursing had to write a letter to verify that I am a registered nurse and legally able to provide nursing services
e. Articles of organization: this came from the secretary of state in my state - LegalZoom helped get this in place too. (Their fee was really reasonable since they laid the path for me.
f. personal NPI
g. CAQH ID and password
h. Medicaid ID and password if your state has it on line
4. Loan: You need to write a business plan. This is a MUST. When you do your business plan, you will think of a ton of things you need, want and this will not only keep you organized it will help you with your financing.
The bank will want your EIN, articles of organization and probably a letter from your state board of nursing. You may have to have your collaborating physician sign on the loan, not as an owner, but just that he/she is in fact, your collaborating physician. This bothered me a little, but I didn't have trouble getting a signature. Your loan expectations should be realistic. Look for office space, think about utilities, supplies, rent, EHR (around $600/month should get you started) Remember that you probably won't be paid by insurance for a few months, so give yourself plenty of time. You can go to the Small Business Association - look on line and you will find that you can get $25,000 without collateral, banks will contact you when you sign up. I applied at a local bank tried to get $50,000 for start up to pay expenses but they wanted me to put my house up as collateral... it was too scary, so I used recommended lender from SBA and got $25,000 within a couple of weeks.
5. Business bank account - Open an account as soon as you can put money into it. Usually need $100 to open the account, but you'll be glad you did. When you pay for things like EHR and for Medicare credentialing, you bank account NAME (name on your checks) must exactly match the EIN so than Medicare will pay you.
6. The EHRs I interviewed - you can find them on line - everyone has their own ideas about how they like their data managed. PrognoCIS, Athena, MediTouch, DrCHrono are the ones I worked with. I ended up with PrognoCIS because they took care of a lot of details for me.
7. Building, utilities: I just signed my lease last weekend. I have the keys!!! The building is empty, need chairs, tables ... exam tables are expensive, but there are some deals on eBay, and look on line for some medical discount places. I'm starting with the bare bones. When you sign up for phone, elect etc. you will need your EIN number here, too.
8. Your bank can help you with credit cards. My bank also has some HR services available, they will write paychecks, have insurance services etc.. it's a bit pricey .. but you can look for services you want to provide to your staff.
9. HR - you need CMS compliance forms - I just learned about this today from the malpractice guy, he is going to send me the paperwork for that. Also need worker's comp insurance and the signage to be in compliance with labor laws. This is on line too.
Make a list of everything you need. It's like playing chess. Moving one piece forward while you wait on others... then you proceed with the next layer...
I made a note book - keeping original documents in there, plus I scanned them into files in my computer. Just keep checking off your list. There's a lit of pieces but you can do it if you keep organized! I am working full time,, just finished my DNP (full time program) and have been setting up this clinic in my spare time...
GO NURSES!! FREE the NPs!! I wish the collaborating practice obstacle would go away from credentialing, financing and malpractice. (I think I forgot to mention.. Insurance companies will not pay you unless you have a collaborating physician, even if you live a state that doesn't require it) UGH!
FREE the NPs!!
Best of luck!

You are amazing!

Neuro Guy NP, DNP, PhD, APRN · Mar 31, 2019

On 3/28/2019 at 10:07 AM, DelanaRN said:
You are amazing!

I went into business as a part focusing on delivering specialty care to Nursing home patients. While I don't see patients clinically except occasionally, I do have employees in my division of the practice (Neurology). We operate in several states. In Delaware, we're independent practice and the insurance companies DO reimburse us even though we have no collaborative physician and we DO have appropriate malpractice, so some of what you said does not hold true in all states.

medj57 · May 3, 2019

On 3/31/2019 at 7:52 PM, Neuro Guy NP said:
I went into business as a part focusing on delivering specialty care to Nursing home patients. While I don't see patients clinically except occasionally, I do have employees in my division of the practice (Neurology). We operate in several states. In Delaware, we're independent practice and the insurance companies DO reimburse us even though we have no collaborative physician and we DO have appropriate malpractice, so some of what you said does not hold true in all states.

So, you didn't need a collaborator for any part of opening your practice?

Neuro Guy NP, DNP, PhD, APRN · May 4, 2019

16 hours ago, medj57 said:
So, you didn't need a collaborator for any part of opening your practice?

Not in Delaware or New York. For New Jersey, a collaborator is required if you prescribe, but in our model we make recommendations only, and thus we don't practice with collaborative agreement. That is, we go to the facility, see the patient, and write the consult documenting our recommendation. The nursing home doctor then has the responsibility to order the meds etc and the facility orders them from their supplier. Pennsylvania, unlike the others, requires collaboration just to practice.

medj57 · May 4, 2019

6 hours ago, Neuro Guy NP said:
Not in Delaware or New York. For New Jersey, a collaborator is required if you prescribe, but in our model we make recommendations only, and thus we don't practice with collaborative agreement. That is, we go to the facility, see the patient, and write the consult documenting our recommendation. The nursing home doctor then has the responsibility to order the meds etc and the facility orders them from their supplier. Pennsylvania, unlike the others, requires collaboration just to practice.

Interesting. Connecticut is a full scope of practice state. Based on what others have said, in a traditional model, it sounds like we still need a collaborator to actually open a practice. Do you know if this is the case?

Neuro Guy NP, DNP, PhD, APRN · May 5, 2019

16 hours ago, medj57 said:
Interesting. Connecticut is a full scope of practice state. Based on what others have said, in a traditional model, it sounds like we still need a collaborator to actually open a practice. Do you know if this is the case?

I do not know anything about CT, but if it is truly a full practice authority state, then no, you should not need a collaborator for any aspect of your practice. It would be good to identify someone as a resource. Also understand, that without a hospital practice or being able to take call at a hospital, it may be hard to get referrals to generate a roster of patients. Often times, for specialties at least, you will need to rely on referrals to generate business until you become established, part of which will require hospital privileges so you can get patients you see and will have to follow up with you in the office.

I suppose it isn't strictly necessary, but would certainly be helpful. And even in FPA states, just about every hospital will require a physician to sponsor you for privileges. So there are still some barriers, but they are not insurmountable. There may be some insurance companies who do not empanel NPs as providers who can bill. It's not common, but they might exist. Or they might empanel NPs, but only if they have a relationship with a physician. Again, not always the case, but I would look into all these matters before hanging your shingle, because you do not want to be excluded from one of your state's major insurers and already be open for business. None of these things were barriers for me. You can find this information out by looking at the various insurers' credentialing requirements. All the websites have this information in the "For Providers" section (or some other similarly worded section of the webpage). PM me if needed.