HOW TO START AN
INDEPENDENT PRACTICE, THE NURSE PRACTITIONER'S GUIDE TO SUCCESS.
With the shortage of primary care physicians throughout
the United States, more and more nurse practitioners are starting independent
practices to help fill the gap. How to start your own successful and _______
practice? Welcome to, The Clinicians Roundtable. I am Lisa D'Andrea, your
host, and with me today is Carolyn Zaumeyer, a Nurse Practitioner and the
author of How to Start an Independent Practice, The Nurse Practitioner's Guide
Hi Carolyn, welcome to ReachMD.
Hey there, it is great to be here!
Carolyn, there are many nurse practitioners who are
currently considering the option of opening their own practice. How much
business knowledge and skill is needed to operate a successful and profitable
When you are first considering opening a practice, you need
to assess your business knowledge and where your strengths and weaknesses lie,
and once you identify what your weaknesses are, you can work on improving those
things and also find experts that can help you with that. You can learn as you
go, but it is best to have a good working knowledge of basic accounting and
business marketing, but you can always call an expert for these things.
Is there a place that you recommend where NPs can learn that
Sure, the SBA has excellent programs all throughout the
country, and if you just go to their website, which is www.sba.gov, you can
find local programs that can give you a basic overview on running a business on
accounting, marketing issues, how to make a plan, how to write a business plan,
all of those things are covered there, and they also have retired business
people with this core program that will actually help mentor you and guide you
through the process of starting a business.
How many years of experience should nurse practitioners have
before opening their own practice?
I would say that the bare minimum 2 years. I have been
asked this a lot. I have many students who contact me that are going to school
and want to start a practice right out of the gate as soon as they get their
license, and I really encourage them to get a couple of years under their belt,
become comfortable and confident in your role as a nurse practitioner before
you put yourself out to the public. You want to practice safely and know that
you are doing the right thing for your patient as well as yourself. So, I
would say minimum of 2 if not more.
And how many NPs own their own practices in US and how fast
is that number growing?
We don't really have real numbers as of to how many
independent practices there are out there, but I see it growing just as I see
my book sale and my request for speaking engagements on independent practice
rising. So, there is definitely the interest out there and I know there are a
lot of nurse practitioners out there with their own practices, but we really
just don't have a good database to tell you exactly how many there are out there,
but I know just from what I have seen that there is a good bit and it seems to
be on the upswing.
What are the reasonable expectations for a nurse
practitioner in terms of profitability when they start own practice?
That really varies on what type of practice they are
starting and who their payer is, how are they getting paid for their services?
You know, are they banking on just getting paid by Medicaid or cash, or is
there a big insurance company that is going to be able to reimburse them at a
decent rate in their area, but it really depends on the location and who the
payer is. I know I was very surprised in my first month of practice. I was able
to cover my bill that was a big surprise to me. So, my overhead for the first
month was paid with my first working month. Of course, I still had debt that I
needed to work on, you know, so it took a couple of years before I was able to
really pay everything off because I kept putting more in for marketing, and you
know, growing the practice. So, it also depends on what you need to take out
of it. You know, if you can keep putting in and help grow it quicker, then you
may get a bigger return on the end.
How do you estimate your start-up cost?
That's a fun process for me. I have developed a couple
worksheets that are in my book where you actually pencil in estimates of what
you think that you are going to need to be paying, you can research your area
because real estate is so very different in all different parts of the country
I can't say that, you know your lease will be 1700 dollars a month where you
know in New York City that wouldn’t be appropriate. So, you can check your
local areas and find out what your rent would be, what your utilities might
be. You know how much are you going to have to pay for staff or taxes, etc.,
but I have a very complete listing of things where you can pencil in what your
one time start-up cost would be as well as what your monthly fees are going to
be, you know, that you can expect, and then from that there is another
worksheet where you can basically estimate what your income will be going with
what you are currently doing in another practice or wherever you are working.
You know how many patients per day, what you can charge for, and it's just a
little worksheet where can get a good guesstimate as what your potential could
be for your income and then you compare the two, you know, is this going to be
financially viable, are my expenses exceeding what my potential income is? You
know, so you can make a decision just doing these worksheets as to whether you
really have a shot at having a successful practice.
How do you recommend an independent practice operated by
nurse practitioner charge for services and could you give some guidance on what
to expect with reimbursement and how to apply for provider status?
The way I designed my fees is I was working per diem in
several different locations for a physician in a private practice as well as
per diem in sub clinic, and I knew that my practice was not going to be a
clinic and I am not a physician, and so I kind of met it in the middle. I
figured I am not a clinic, I have nice carpet, I have a nice office, but I am
still about a doctor. So, I took both of those, these provided access, so you
know what they were charging and I kind of met it in the middle and found an
appropriate price that I felt I would pay as a patient, and most of my patients
were cash-paying patients, so I needed to keep it affordable and I was able to
do that by meeting it kind of in the middle between a clinic and a physician's
So, let's talk about the scope of practice. How is that
defined with an independent NP practice?
The scope of practice is defined by your specialty, by your
profession, you know, your area of expertise and the law, as well as your
agreement with your collaborating physicians. So, you need to know where your
scope of practice is, what you are trained to do, what's you are confident at
doing, what you are competent in doing, and go from their, and then if you ever
feel like you are approaching that line, that's when you refer out, and it's
all basically a judgment call for me in my head. You know, is this something
that's appropriate for me to be doing or is it not because if you step over the
boundaries and you practice outside your scope of practice, you are not doing
yourself or the patient any favors. You need to practice with what you know
and follow the laws of your State.
So, tell us some of the positives and negatives of NPs in
Well, the positives for me were autonomy. I was able to
practice the way I felt was appropriate, treat the patients along with guidance
from my collaborating physician in the most effective kind and affordable way I
was able to provided health care. I was able to set the schedule and be
flexible for my patients, but it also was flexible for me. I could still teach,
I could travel. The flexibility was very, very good for me, plus I am in a bit
of control freak and having control over how my practice ran, how clean it was,
how the employees treated the patients, communication, that was very important
and rewarding to me that at the end of the day I truly was able to say that I
gave the patients the time, the consideration that was required and necessary
and a lot of times over the line, you know, we really extended ourselves out
for the patients and saw many patients that would not be seen at other
And what is about negatives?
I try not to focus on the negatives. I always felt like if
there was a barrier or roadblock that I would find a way around it, under it,
over it, knock it down. I didn't have any negatives. I mean it was just
really a very positive experience for me, I would say may be the reaction from
the insurance companies because I started my practice back in 1992 which does
not sound that long ago, but it was a long time ago and I sent out over 200
query letters to insurance companies and I got the most bizarre responses.
They decided that advance practice nurse was really an LPN and why would she
have her own practice, you know, things like that. Out of the 200 letters that
went out, I got 3 positive responses. So, I think the insurance companies, you
know, that will be a negative. If I have to look out at that way, but what I
did is with that knowledge that they really did not know who I was and was I going
to really take the time to educate them or was I going to revise my plan? I
did the research to find out how many of the population in my area were
uninsured and with that I had the confidence that I could start a cash practice
and run that practice just basically with cash, provide the patient with a
super bill with all the fees and charges and all the codes they need to submit
to their insurance if they choose to and that worked out well for me.
Carolyn, you mentioned earlier about laws regulating scope
of practice. Could you explain that a little bit more?
Every State is different and they really vary widely, as
what the laws entail and it is your responsibility as a nurse practitioner to
research the laws and know the laws, and follow the laws. There are
differences as far as the law collaboration with the physician or supervision,
the way it is written, the prescribing is different whether you can write for
controlled substances or you need to have a physician's signature or what needs
to be printed on the prescription pad, everything is different State by State
and you need to know what the laws are because, you know, that you are
following all the rules of the law.
You also mentioned that your practice is a cash-pay
practice. Are most NP practices run that way?
Not really. I have been speaking throughout the country to
nurse practitioners in the independent practice and they are as varied as they
can be. Some depend wholly on HMOs or insurance reimbursement, some are cash,
some are Medicaid based or they are serving the indigent working on grants, so
the payer is very, very different depending on, you know, where they are and
what type of services they are providing.
So, what are the top 3 mistakes made by nurse practitioners
when starting their own practice?
I guess, like with any business, not planning the finances
properly, not having enough capital, and may be not marketing properly, doing a
good marketing plan, so that you get the word out, so that people know that you
are there so that they can come.
What marketing activities do you recommend that the nurse
I think most importantly is to write out a yearly plan, so
that you are not just throwing money here and there and hoping for the best.
You need to have somebody guide you that are an expert in marketing as to print
advertising, TV commercials, in the movie theater, all kinds of different
things. One of our most successful things was a special we put together for
STD testing. In my area, it is a quite promiscuous area, and so I put together
a package of STD testing, HIV, syphilis, chlamydia, and gonorrhea for like 75
dollars, and then we run these ads and these magazines that cater to the
nighttime, you know, concerts and movies and all that, and, you know, ________
all things like be kind to your valentine, get tested today, you know, so just
a little fun different things like that to get the word out to the public that
you are there and also networking, you know, going around and meeting people,
shaking hands, and projecting that you are a confident business person as well
as a provider.
Do independent practices employ physicians to work on staff?
Some do, yes. I have been reading about some that do employ
physicians and a lot of them are very successful, so you can work both ways.
It could be very good for the physician as well as for the nurse practitioner
business owner to have that relationship.
I want to thank my guest, Carolyn Zaumeyer, for coming on
I am Lisa D'Andrea and you have been listening to The
Clinicians' Roundtable on ReachMD XM 157, The Channel for Medical
Professionals. Please visit our website at www.reachmd.com, which features our
entire library to on demand pod casts and thanks for listening.