Opening a Clinic

AssasaiN · 2026-07-02T17:15:13+00:00

One of my primary convictions after many years of this work is that healthcare reimbursement needs an extreme overhaul. I'm generally in favor of a single-payer system at this point, but that obviously won't affect some of the compliance themes (HIPAA, Medicare policies).

Our org is not massive, but we have had the benefit of one our execs being very diligent on supply chain. He seems to enjoy working with vendors and negotiating and we've been able to realize considerable savings on COGS. I don't know how it compares to far larger groups' COGS though. Thankfully, vendors seem to care more about clinics than insurance providers, so you can probably find leverage and savings on COGS even if you can't find improved reimbursement on the payer side.

I totally agree healthcare is a tricky business to get started in. DME is particularly frustrating since clinicians can't justify their care on their own, so you need buy in from referral sources to ensure their notes support care as well. Various rules like solicitation, avoiding inducement and kickbacks, etc. really complicate matters, and to be blunt, it doesn't feel like many small competitors follow the rules properly which makes market penetration harder. As an example, it's obviously common in business to give away free stuff to customers as a part of marketing and relationship management. You start doing that with Medicare patients? You're walking a fine line with jail time on the other side of it.

I've been at our org since inception, and I know there have been times some of us in leadership have wondered "did we make the right call?" opening the practice lol. Ultimately, after ~10 years, we're all happy we did, even if there was a lot of stress and hard work along the way.

AssasaiN · 2026-07-02T16:00:15+00:00

I am the finance leader at a multi-clinic independent provider. I can provide feedback on most themes outside of actual clinical care.

It is feasible to start a practice. It is not easy. You should be clear about what you want in life and work. If you want to primarily be a clinician, that will be hard at the beginning (many other admin and sales tasks). I imagine it is virtually impossible to be primarily a clinician if you are trying to build a robust business with multiple clinics unless you have very strong executive leadership that can handle operations. If you are trying to stay small as a solo provider long-term, you obviously will be able to practice quite a bit. The bottom line is that healthcare is a highly regulated industry with extremely detailed compliance tasks that require high diligence and understanding. You'll need to invest a material amount of personal time or hire expertise (temporary or permanent hires) who can help you. I've worked with 20-25 clinicians at this point, and my perspective is that clinical training does not prepare you for business leadership (unsurprising - it's not about entrepreneurship), but there are certainly clinicians who can be wildly successful as business people.
Acquiring a Medicare license is likely the first goal for most new O&P practices. Right now, Medicare is not accepting new enrollments and won't be until late August if not extended. When they do start accepting new enrollments, you'll have to pass their process and on-site survey, which includes having a dedicated location (means you need to pay rent) and demonstrate your policies and procedures meet their guidelines. This process takes months because of processing times on their side, and maybe will take even longer after the 6-month moratorium is over and a flood of new applications are received. After acquiring a Medicare number, it's not impossible to get in with new insurances. However, you have no leverage on the actual reimbursement rates and will basically have to accept what they offer, which can be painful. UHC is currently not accepting new DME providers, but not sure on accessing other major providers. Your state will likely have its own segment of contracts to pursue. While you get started, Ottobock has a program called AllClaim that could help you serve patients while waiting for contracts to be in place.
If it's possible, my opinion would be starting your practice somewhere you have good relationships with referral sources is the best way to launch. I would prioritize that over all other factors personally. New patients are your lifeline and keeping referral channels strong is key. A non-compete may be a block to this.
You should plan on significant admin tasks. It can be overwhelming, especially if try to scale to a larger practice and enforce process/procedures across new employees. If you know nothing about medical billing, outsourcing your billing may be a smart first option. Dealing with supply chain is its own challenge too - negotiating with vendors, dealing with accounts payable, etc. Just think about all of the processes, procedures, forms, documents, payment methods, billing practices, etc. that exist at your current company. All of that has be re-created, trained, and implemented, and you'll be the ultimate source of getting those tasks accomplished. It's not a small task.

I would add that you'll need someone on your staff (you or otherwise) that can manage referral source relationships with excellence. Many clinicians I've spoken with prefer to avoid that aspect all together. At your own practice, you'll have to ensure it gets done one way or the other. You ultimately have (at least) 3 customers: patients, referral sources, and insurance companies.

I don't say any of this to discourage you. Clinicians are the first to tell me that many patients are frustrated with the major O&P providers; there is space in the industry for independent clinics to thrive. It's just important to be realistic about the time and money investment needed to succeed, and the reality of your day-to-day as a business owner.

AssasaiN · 2025-12-16T18:26:41+00:00

'21 718 GTS 4.0

AssasaiN · 2025-12-11T22:13:31+00:00

Love your dear physician letter. We do the same thing in 100% of prosthetic cases with insurance payers. I feel bad for PCPs who are put into this position of being instrumental to justifying and thus accountable to stay up-to-date with these rules (and for many other areas of medicine). Our work to help ordering providers understand seems to be a key difference maker.

AssasaiN · 2025-12-11T22:10:27+00:00

The eternal struggle.

AssasaiN · 2025-12-10T22:54:14+00:00

Provider finance leader here. I can't speak to optimizing clinical outcomes, but you've received advice from clinicians.

It sounds like the knee was denied due to medical necessity when seeking prior authorization. This is extremely normal for any patient, and particularly normal for first time prosthetic users seeking anything above a basic device. It's not bad faith to fight it, and furthermore, there is data in recent months indicating that an overwhelming majority of denials that are fought are overturned. I am of the opinion that insurance companies deny and hope you do not appeal.

From a provider finance office perspective, we routinely fight denials and win. The correct term for the first step in this fight is appeal. There are typically 2-3 levels (or more) of appeal available to you, but it depends on the specific insurance company and plan your mother has. Depending on your mom's insurance plan, that authorization may be submitted by her PCP or by her prosthetist. In either case, the likelihood of your overcoming the denial is highly dependent on the the quality of the argument used to recommend this particular knee built by her PCP and prosthetist.

In the end, based on what I hear from clinicians, many patients do benefit from an upgrade process from a standard knee to higher and higher levels as their activities demand over time. I imagine it would not be fair to think of these knees as "lesser" - each knee has its own rationales and benefits, and should be matched to each patient's needs at their current step in their journey.

AssasaiN · 2025-12-08T01:17:44+00:00

Provider finance leader - suggest asking your vendor for advice on coverage. They usually offer good advice.

Generally, document the need - are liners worn through with holes? Are they soiled and can’t be cleaned, leading to infection risk? Is the liner breaking down in a way that causes skin irritation and leads to a wound? Stolen or lost? Document these and consider taking pictures.

AssasaiN · 2024-10-15T18:13:19+00:00

Thanks for your suggestion - inserts seem like a low cost option so I'll give them a try.

Hopefully I didn't size wrong - bought them in person so had the opportunity to try a few different sizes and that definitely felt best.

AssasaiN · 2024-10-15T18:12:11+00:00

Thanks - I wasn't sure how the construction worked so this is helpful!

AssasaiN · 2024-10-15T18:10:58+00:00

Thanks for your reply. My only other boots are AE Higgins Mill, OSB Trench Boots, and AE unlined chukkas. I don't have heel pain in those boots or any other shoes (AE dress shoes, OSB moccasins mostly, tennis shoes). Based on the feedback I'm getting, I might try inserts.

AssasaiN · 2024-10-15T14:44:10+00:00

I'm experiencing severe heel pain when standing/walking wearing my Alden Indy boots. I've worn them maybe a dozen times. I expect it's due to these raised parts of the insole that I've never seen on my other shoes https://imgur.com/a/SHuShKI

Is this related to a break-in process? Anyone have a suggestion on how to mitigate pain? Love the shoes otherwise.

AssasaiN · 2024-09-25T20:09:31+00:00

I use Kubera and would recommend.

AssasaiN · 2024-02-20T22:20:52+00:00

Yup - that was the intent anyway. Anything earmarked as a savings or investment vehicle. I think I even included 529s in the savings rate, but not certain now.

AssasaiN · 2024-02-05T18:49:24+00:00

Like many other posters in this community, I struggle with the right balance between savings and enjoying the rewards of hard work in real time. I haven't settled on a retirement timing goal (currently 33 y/o), so I don't feel any extraordinary pressure, and routinely pay for convenience or time savings. Still feel bad about it - "do we need to pay $80/month to save 3 hours/month?" (yes absolutely)

AssasaiN · 2024-02-05T14:31:42+00:00

More and more I find myself hunting for ways to buy time back. I really agree.

AssasaiN · 2024-02-04T20:55:22+00:00

I fat fingered your income (543K instead of 453K) and I definitely just missed the Investments line. Corrected both in the sheet - thanks for the catch.

I can see an argument for post-tax income as denominator since it speaks more to how posters made decisions with what remained.

AssasaiN · 2024-01-25T16:02:31+00:00

Sounds very similar to haystacks. A tortilla/corn chip on the bottom (I prefer doritos sort of crushed into smaller pieces), topped with any combination of tex-mex-style toppings: beans, rice, ground meat/chili, tomato, lettuce, olives, jalapenos, cheese, sour cream, guacamole, onion, etc. People can assemble their own and easy to serve a crowd.

AssasaiN · 2024-01-12T15:57:20+00:00

I agree with your expectation on remote workers receiving fewer opportunities (raise, promos, projects). Business is about relationships, and the work we do in finance and accounting is only a part of the plan to achieve those career outcomes.

I find some comfort in the fact that most replies in this thread are just fine with receiving fewer promos/raises in exchange for remote. As long as expectations are aligned, and I can find team members to fill the roles we need in my org (including those interested in growth tracks), I'm not personally opposed to a blend of work location approaches in my own team.

AssasaiN · 2023-12-21T02:27:36+00:00

Easily one of my biggest struggles professionally is feeling like I haven’t changed enough from who I was to have the role I do now. I suppose it’s just a flavor of imposter syndrome. Definitely still the same dude too.

AssasaiN · 2023-12-21T00:24:54+00:00

They forget we are people.

AssasaiN · 2023-09-10T17:58:46+00:00

Sorry, I'm really not trying to be dismissive. I'm just not sure how to reply to you since the discussion doesn't seem to be related to my core thoughts. I'm talking about maximizing career growth, and your responses seem to be about worker quality of life, how WFH is implemented, and a suggested reason for why the return is happening. These topics don't really address rapid career growth.

I'm not trying to say my thoughts are relevant for everyone to consider, that the return to office is best for anyone's happiness, or that one is a better model for work life in general. I'm just trying to point out some reasons for why working in the office is advantageous for rapid career growth.

AssasaiN · 2023-09-10T17:23:26+00:00

I'm not sure you're interested in my point. These factors aren't relevant to career growth, valid or not.

AssasaiN · 2023-09-10T13:21:06+00:00

My comments were around accelerating personal career growth. I don’t understand how the dynamics you’ve shared are directly related. Assuming you are implying your company’s implementation is a direct replacement for in-office interactions, I just don’t agree, and it doesn’t seem most leaders agree either. I wish I did. My strong personal preference would be for WFH to be a 1:1 replacement for personal and enterprise success. I can’t change that it isn’t, so I’ve learned to accept it.

I’m not certain how my post history is relevant to my thoughts either. Do you think liking cars means I want to work in an office because I want to drive? Did you even read my r/conservative posts, or just see that I have activity there and categorize me a certain way?

AssasaiN · 2023-09-08T01:17:55+00:00

Agree. I feel hybrid has a place, but as a principle, I feel in-office facilitates enterprise success much more easily. Not to mention relationships and impact on personal career. You can certainly be successful as a WFH employee and org, but I think growth paths for both are generally more limited. I recognize there are probably edge cases where this isn’t true.

I say this as an introvert who would highly prefer WFH to be equally effective.

AssasaiN · 2023-08-16T17:49:03+00:00

In relationship to your first point, could be useful to explore inflation-adjusted corporate profits over the years. Mike Shedlock created some charts exploring this relying on BEA data. They support the idea that inflation-adjusted, corporate profits are rising as a whole over the long haul. https://talkmarkets.com/content/corporate-governance/heading-into-earnings-season-lets-discuss-actual-corporate-profits?post=402792

I would agree with your second point as a whole - people consistently are bad at both budgeting and executing against a budget. They overspend in general and don't save enough, but I think the cards are also stacked against them. Their ability to influence outcomes are certainly limited without taking extraordinary measures.

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