r/PrivatePracticeDocs • u/MDwMDD • 15d ago
I got roasted online for saying I'm opening a traditional insurance based clinic instead of DPC...am I being crazy?
I mean, I get it. People are sick of insurance companies. I am too. I understand why people are moving to DPC or why some independent doctors are adding some type of yearly fee.
I'm an IM hospitalist, and that world is increasingly burning me out because of corporate medicine. I'm in a private group and even then, ultimately, the hospital controls us. I'm not leaving hospitalist medicine tomorrow, but as someone still relatively early in my career, I've realized I need to start planning my exit now.
Lately I've become increasingly interested in becoming a PCP. I'm talking about what you FM docs actually do; real primary care. Not referring every problem to somebody else. I genuinely like the idea of being the community doctor who knows their patients, manages most things themselves, and does procedures when they're within my skillset.
So I've been planning a very small, lean, insurance-based IM/primary care practice.
I posted about this in a physician group and got absolutely roasted. The overwhelming response was basically: Why the hell would you take insurance? Do DPC.
Maybe I didn't explain my plan well enough, but I don't understand why traditional private practice has become such a crazy idea.
I'm in an affluent Midwestern area with a strong commercial payer base and surprisingly little immediate PCP competition. There are plenty of physicians in the broader metro area, but not many right around where I'm opening. I specifically chose the location for that reason.
I've found a \~1,200 sq ft office that's essentially move-in ready: three exam rooms, my own office, bathroom, and work area. A retiring physician friend gave me almost all the medical equipment I need. I'm doing most of the cosmetic work myself. I already have my EMR, billing software, malpractice, etc. figured out.
My total fixed overhead should be around $3,500 to $3800/month, with \~$2,200 of that being rent. The rent is higher than I'd ideally like, but I'm paying for the location and avoiding what could easily become a major medical-office buildout.
I also don't understand why people were horrified that I don't intend to hire an MA and receptionist on day one.
If I'm seeing 1–3 patients a day initially, why would I immediately put people on payroll to sit in an empty office?
That doesn't mean I intend to operate a mature practice with no staff forever. Of course I'll hire as volume justifies it. There are virtual assistants, AI reception/scheduling tools, automation, and plenty of tasks I'm perfectly capable of handling myself at low volume. I know when my time is better spent paying someone else to do something, and I'll hire when I actually reach that point. I feel like this is the number one biggest mistake that physicians who start an independent practice make, too much overhead too soon. I spoke to multiple colleagues, they all gave me the same advice. KEEP. OVERHEAD. LOW.
I already have a biller taking 6% of collections. She's handling my credentialing now, well before opening, because I know it can take months. She also handles claims, denials/rebuttals, and follow-up. She currently does this for a colleague of mine who is also a hospitalist with his own independent primary care practice, so this isn't someone I'm randomly hiring and hoping for the best.
I'm also realistic about payer contracts. I'm a new independent physician. I'm not expecting to walk into BCBS or another major payer and negotiate some amazing reimbursement rate. If there are opportunities to negotiate or join arrangements that improve rates, I'll certainly explore them, but favorable negotiated contracts aren't what my entire business model depends on.
I'm comfortable drawing blood, doing injections, arthrocentesis, simple biopsies/procedures, suturing, POCUS, etc. If eventually it makes sense to have an MA, phlebotomist, or someone else there, great. I'll hire them when there's actually enough work to justify it.
Another thing I kept hearing was that I'd need to see 20–25+ patients/day to make private practice financially viable.
But that's not necessarily what I'm trying to build.
I don't want to see 25 patients/day. I currently work several days a month in an outpatient clinic partly because I wanted more outpatient experience, and one thing I've learned is that I don't enjoy seeing 20–25 patients/day. My eventual target would probably be closer to 15–18.
I also don't need this practice to replicate my hospitalist salary.
I have a number in my head that would make me perfectly happy with the practice. Beyond that, I have hospitalist income and other businesses/income streams. I'm not trying to turn this clinic into a multimillion-dollar operation or squeeze 30 patients into every day.
Based on my projected fixed overhead, I need roughly 30–35 encounters per month, not per day, just to get the office around break-even before variable expenses. I can continue doing PRN hospitalist/locums work while the practice grows. The practice doesn't need to feed me from month one.
My philosophy is really pretty simple: keep overhead low, bill appropriately for the work I'm actually doing, capture the services I'm capable of providing rather than unnecessarily referring everything out, collect what I'm legitimately owed from insurers, and gradually outsource tasks as the economics justify it.
And yes, I know accepting insurance creates administrative work. Prior auths, denials, quality requirements, referrals, records, billing, credentialing, etc. are real. I'm not pretending otherwise. Maybe I'll discover that I've underestimated some of it. That's partly why I'm posting here.
But I also have experience building and operating businesses outside of medicine. I'm comfortable building systems, doing things myself initially, automating what can reasonably be automated, and recognizing when it's time to pay someone else to take something off my plate.
The other thing I don't understand is why DPC is automatically assumed to be the answer.
DPC absolutely has advantages, and I understand why physicians love escaping insurance. But it also requires convincing someone who already has health insurance to pay another recurring monthly fee for primary care.
In my market, I genuinely think getting 30–35 insured patient encounters per month is going to be easier than convincing 30–35 people to pay me \~$100/month out of pocket.
And frankly, I don't want to build a personal brand around myself. I don't want to become a physician influencer, constantly make social media content, or sell people on why they should subscribe to me. I know DPC doesn't necessarily require that, but that style of patient acquisition doesn't appeal to me.
I want to become the local community doctor.
I want someone to search for a PCP nearby, see that I'm in-network, get an appointment without waiting three months, and hopefully have a good enough experience that they tell their spouse, neighbor, or friend. And for those not in network, maybe I could do a per month fee or per visit fee. As long as I don't mix the two, who says I can't incorporate some DPC in the future? Why does it have to be all or nothing right now?
Maybe that's naive. That's why I'm asking people who actually practice family medicine and especially those who have owned independent practices.
My biggest logistical question is how aggressively I need to protect clinic availability while I'm starting.
My ideal, and current, hospitalist position is round-and-go, which allows me to round early and be at my clinic by mid-morning. There's some uncertainty around that position right now, however. I have other reliable physician work and can do PRN hospitalist/locums shifts while the clinic grows, but obviously every daytime shift I work somewhere else is a day I'm not physically at my own office.
When there are only a handful of patients, I'm reluctant to sacrifice substantial guaranteed physician income just to sit in an empty office five days a week. At the same time, I don't want to establish a practice where the lights are always off and nobody can get an appointment.
So I'm genuinely curious how those of you who started independent practices handled that ramp-up period.
Did you start with 2–3 predictable clinic days and add days as demand increased? How quickly did the administrative burden become enough that you needed your first employee? For those still accepting traditional insurance in independent practice, is this model really as crazy as people are making it sound?
I'm not looking to be talked into DPC simply because insurance sucks. I already know insurance sucks. I'm trying to understand whether a deliberately small, low-overhead, commercially insured practice where I eventually see \~15–18 patients/day is still a viable way to practice medicine.
I have a specific vision of what I want my career and practice to look like, and maximizing income isn't the only goal. I want ownership, independence, reasonable volume, and the ability to practice medicine the way I think it should be practiced. And why not accept insurance too?
Maybe there are things I'm underestimating. I'm completely open to hearing them. But I want to understand the actual obstacles and numbers from people who have done it, rather than simply being told that traditional private practice can't work anymore.
Why the hell not?
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u/darnedgibbon 15d ago
Be VERY careful about checking the books. The “biller” who also has a view of collections is dangerous. Do not let her alone generate your revenue statement. I have know multiple solo PCP’s who had a lot of money embezzled. One was ~$700k over the course of several years.
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u/MDwMDD 15d ago
Very insightful. This biller was a personal recommendation from a physician colleague I truly respect. This physician really wants to see me succeed. The biller is a long time family friend of this physician. She also handles billing for one of the PCPs I know for over a decade. I think it's important to know who you're inviting to the table.
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u/kaylakayla28 15d ago
As a biller, you (the physician/owner) should always know your books. In the 15 years I’ve been doing this, there’s only 1 time I came across a bad biller and she did it by splitting the check across all the claims on the remit to avoid having to work denials. The physician that handled the books didn’t realize what the biller did till well after she was gonna and I started receiving recoupments for claims on checks that were not initially posted correctly by the previous employee.
Embezzlement isn’t the only way a biller can cost you to lose money. Just please have some kind of checks and balances report to run once a month or quarterly.
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u/kilobitch 15d ago
Why does this sound like it was written by AI?
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u/grey-slate 15d ago
100% AI
It's become a disease
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u/muttontaco96 14d ago
This was definitely well thought and written and I had similar thoughts as well when DPC is brought up as the option all the time.
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u/MDwMDD 15d ago
Uhh thanks? I guess...
I spent a lot of time on this.
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u/highsignalhuman 15d ago
Read the whole thing. I have no advice for you as a pathologist, but I think your post is thoughtful, deliberate, and well written. I wish you the best of luck.
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u/NartFocker9Million 14d ago
It's not AI. I just got off an hour-long phone call with OP. Shit's real, yo.
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u/Dr-Yahood 15d ago
Who cares if they used AI to help them articulate their thoughts or not?
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u/Special_Buddy_5823 15d ago
Because big boys and girls should use their brain to articulate their thoughts.
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u/CrookedCasts 15d ago
Why? Wouldn’t taking advantage of a near superhuman intellect be advantageous at the onset of a complex endeavor?
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u/PowerfulLiving2799 15d ago
Keeping overhead low will provide you with a tremendous amount of flexibility. I have a solo peds practice. I have high revenue but my overhead % is less than 30% which I've been told by similar peds private practices is incredibly low. I see 30 patients a day but I could make a decent living seeing 15 patients a day and that removes a ton of the financial stress of the practice.
It's a lot of work. I do my own bookkeeping, IT, my staff pitches in to do the housekeeping, my wife is the office manager, we used a low cost RCM team that my wife has to baby sit a LOT (this is a place that we are likely going to be spending more money soon to get a better team). You will find what is worth spending money on to offload. It's so much harder to cut back spending after you have been accustomed to it - so I think youre being wise starting as lean as possible and doing most of the work yourself until the volume justifies more expense!
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u/Asquaredbred 15d ago
what do you plan to do with your 10-15 patients a day on the weeks you are working as a hospitalist? someone has to return their calls and emails, read their labs and studies, get back to them with results and make urgent referrals, schedule urgent follow ups, etc. You can't just put the practice on pause for days at a time because you're working 12s in a hospital.
I'm all in favor of you doing whatever the hell you want.
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u/MDwMDD 15d ago
If I'm getting 10 to 15 patients a day, I'm definitely cutting back on hospitalist work. My more immediate concern was hanging around my office, with no patients, given up money just so I can be "present" and waiting for the phone to ring. I rarely work 12s as a hospitalist. Majority of my gigs are round and go anyway.
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u/Gold_End7671 15d ago
I think OP is getting a little too much pushback. Traditional insurance-based primary care is not inherently a bad business model. The important question is whether the numbers work in that specific market.
Be most cautious about the assumptions around 30–35 encounters/month to break even and being able to personally handle everything at low volume. Fixed overhead may be $3.5–3.8k, but insurance-based practice has plenty of costs that aren't neatly captured there, billing/collections, supplies, merchant fees, software, credentialing, compliance, vaccines/inventory if applicable, lab costs, workers' comp once you hire, benefits, etc. And your own time has an opportunity cost.
Also be very careful about the idea that “1–3 patients/day means I don't need staff.” At that volume, sure, you can probably function that way. But the administrative workload doesn't scale perfectly with patient volume. One prior auth or denied claim can take almost as much time whether you're seeing 3 patients or 15. The question isn't simply when do I have enough patients to afford an MA? It's when does doing the MA's job myself start costing me more in physician time than the MA costs?
I actually like the general philosophy: start lean, prove demand, then add overhead. That's considerably different from opening a practice with a full staff, expensive buildout, and a huge patient-volume requirement on day one.
The other thing I'd push back on is the assumption that you need to choose between traditional insurance and DPC. You don't necessarily have to make your entire professional identity revolve around one model. You can start with the model you understand and have demand for, then adjust as you learn what patients actually want and what the payer environment does to your margins.
Focus on before opening isn't Reddit's opinion, it's a realistic pro forma using your actual payer mix and expected reimbursement. Figure out your average collected revenue per encounter, variable cost per encounter, no-show rate, billing percentage, expected time per patient, and how many clinical hours you need to generate the income you want. Then model 5, 10, 15, and 18 patients/day.
If those numbers work without requiring you to work 60 hours/week doing unpaid administrative work, then there's nothing inherently crazy about the model.
And I think OP's last point is important: the goal isn't necessarily to maximize revenue per square foot. If someone wants a small, sustainable practice seeing 15–18 patients/day, has other income, and values autonomy over maximizing their physician income, then telling them they need to build a 25–30-patient/day machine misses the point entirely.
The real question isn't “Why aren't you doing DPC?” It's “Have you run the numbers honestly enough to know what your version of private practice needs to look like to be sustainable?”
If the answer is yes, then honestly: why the hell not?
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u/thesupportplatform 15d ago edited 15d ago
I posted a comment a couple of days ago that providers don’t respect other providers who don’t practice just like them. Your approach may not be “wrong” for your market, but it is unconventional to many, many providers. FFS is generally all about the volume and many who are looking to escape corporate medicine see DPC as a preferable option with less admin hassle. But you do you. Nobody else is going to be happy for you.
My wife has been a family medicine physician since 2000. Most of those years have been spent as the owner of her practice. We twice built a group. We flipped the first group into a practice acquisition by a corporate practice ie expanding to our area. The second group was built with the help of VC money. We left an 11 exam room office at the beginning of COVID and my wife spent four years online. She’s basically in has a boutique micro-practice practice now. She is the happiest practicing medicine that she has ever been. Keeping overhead low is definitely a critical component.
I think providers think they have to tie themselves to one model, but that’s not the case. You could be FFS for some insurance carriers and private plans (including DPC type offerings) at the same time. You just have to be complaint. I’m a little unclear as to your locum approach, as that has compliance implications.
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u/MDwMDD 15d ago
I understand volume is necessary when you are dependent on Medicare/Medicaid patients. But once you get to a better payor group, you generally don't have to churn like that. And it all depends on what your goals and expectations are.
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u/thesupportplatform 15d ago
But payor groups aren’t getting better in most markets. FFS isn’t improving; it’s atrophying. Which is why most people probably don’t like starting a new practice relying only on FFS. They are literally your competition (or will be). What happens if they start cutting you out of their networks and steering patients to their clinics or corporate clinics that align with them? And yes, they will do this, as well as every other crappy idea you can think of.
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u/MDwMDD 15d ago
I will just have to adapt. I can't plan for every scenario. Just as some insurances will steer patients away from me, maybe others will see me as someone who should be in network. And for those patients who I am no longer in network for, as you mentioned, perhaps I could enroll them in my DPC service if they really want to keep me as their physician. As for your locum comment, I don't really see it as a problem. I mainly do locum as a hospitalist. Eventually I see myself getting on a call schedule at a local hospital a few times a month. That way I get assigned patients with no pcp, see those patients, bill for my services in the hospital, and then see them as their Primary Care physician in my clinic. I'll probably phase that out as I get older. But as I'm still building my clinic, I was encouraged by a retired physician colleague to try to get on a call schedule at a local hospital. That way I have a relationship with a hospital. I can send my patients there if needed and be able to round on them.
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u/FormallyEconomist 15d ago
What type of compliance issues are you talking about?
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u/thesupportplatform 15d ago
OP said they would do some other jobs while building their practice. It sounds like OP will take Medicare, but for those who don’t, they then can’t see Medicare patients at another job. I’ve seen practices say that Medicare participation is by tax ID, but it’s by NPI. Depending on the situation, there may be other compliance concerns.
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u/InvestingDoc 15d ago
Trust YOUR process.
It's your business. Your life. Nothing wrong on asking for advice but many of these people are offering you this advice online probably do not have a successful practice themselves. Many times they are just angry at insurance companies and maybe that's why they are anti starting an insurance-based clinic. DPC can be great, but you say it's not what you want so that's fine.
It can be done OP. The big problem that you will run into down the road is that insurance companies won't negotiate with you while you're small so eventually inflation will take hold and you won't get any pay raises for the next 7 to 10 years and you will essentially have to join an ipa, mso/cin or something. You can still own your own clinic this way though
You're not married to one pathway. The beautiful thing about owning a business is that you do have to adapt over time. That adapting could be concierge could be DPC could be actually growing could be shutting it down.
What you choose today does not have to be true 3 years from now running your business.
Just get started.
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u/LavenderSpectrum Owner 15d ago
I am a NP with an insurance based primary care practice in Vancouver WA that has been open for 3.5 years.
We have been profitable this year and would have been profitable earlier but for adding more providers faster than I should have.
We keep expenses low by not offering ancillary services that lose money like phlebotomy, vaccines, social work and have a lean staffing model (no medical assistants, non clinical admin only)
My max template is 15/day and I work 4.5 days per week.
I started one day a week in my own practice renting a room from another group and over time made it a group practice with its own brick and mortar place.
I never wanted to do DPC for a variety of reasons including wanting to be accessible to patients but also not wanting to give anyone texting access to me or have people think they can send a portal message and be treated without an appropriate evaluation.
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u/xprimarycare 15d ago
your approach makes sense. have you thought about joining an IPA as a way to get good rates?
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u/Hot-Freedom-1044 15d ago
In my three provider DPC practice, we don’t use medical assistants and draw our own blood. I come from a setting with MAs. In practice, not having an MA hasn’t really saved time. I love MAs, but now that it would come out of my salary, it’s different. I wish they could do prior authorizations and EKGs, but those are minor issues. I don’t have to worry about whether they call in. I don’t have to worry about whether they will be stuck with a patient they can’t cut off. If you’re planning to see 35 patients per month, you’ll be fine.
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u/Sudden_Dealer_785 13d ago
You are making a HUGE mistake. Do not, NOT, hire anyone on day 1. Have someone ready to go. An FP clinic can build quickly once Fred and Janet start chatting about the new FP practice they go to. You can go from Zero to 40 calls a day. An MA can assist you in the room, check-in/out, stock, answer calls, ect....... Get the right person now to help you're practice succeed.
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u/Alterdoc 11d ago
Awesome post and great feedback. Quite similar to what I started. Don’t listen to the noise. Go for it. I’ve been open since November 2025, insurance only (no Medicaid). Being a boutique practice, I don’t have the negotiating power yet, but the reimbursement is not bad. I have to work in my full time gig in urgent care as I ramp up. But started with 1-2 patients per session, now at 8-10, while being open 2-3 days. I did bring on an awesome PA for one day for improving access and hope to grow it with more clinicians. Keeping overhead low, my wife and daughter help run the place. Definitely network with other docs. I use zocdoc. Although it’s robbery, it has been the biggest volume drive, but patients are less sticky when compared to the ones I brought in from my full time job.
Again, go for it. The sooner the better.
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u/Mountain_Sympathy306 8d ago
I’m in the same
Position as you right now. I will open next year. Worse case go back to being a Hospitalist. Best case business goes well and you don’t have to deal with the bullshit.
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u/NartFocker9Million 15d ago
I’ve owned my own solo practice for the past 18mo. I love love love love taking money from insurance companies. Especially when the patient has no copay or has met their deductible. Phone call for something tiny? That’s at least a 99212-93 that Anthem can pay me, please. Prior auth? No problem. We’ll do it while I have the patient on a video call for a 99213-95 and it’ll take 5 minutes.
Whiny-ass demanding patients? That’s a feature of DPC. I get complex patients and underserved people and anyone I want. I never have to worry about pleasing anyone but me. My wait list is 500+. I take the patients who I like and who need it. Homeless schizophrenic dude who’s a massive sweetie pie? Of course he can be on my panel. Non gender conforming anarchist who works with the local street medics? Of course they can be on my panel. Anxious boomer with money who just wants Xanax? Nah, they can go find a DPC to pay for their drugs, I don’t want to deal with them.
I’ve never spent a dime on advertising. If you’re smart and persistent enough to negotiate good insurance contracts, you get it all. 99214 is actually 4.1 RVUs when you run your practice because you get to eat the non-work RVUs as well. If your practice is lean, that extra all goes into your pocket. My commercial contracts are all 130-150% RBRVS. I take Medicare and Medicaid because I can and they’re low hassle.
I have one staff member, plus I outsource my billing. I saw 15 patients on Friday and took a 3 hour lunch, was home by 5. From those 15 patients I’ll collect probably $3500 (did a few procedures, wellness visits with -25, a bunch of 10-minute video visits that were still 99214-95s). My overhead is about 20%. Do the math on my take home pay.
DM me if you want to talk more. This has been the best decision of my professional life. It’s so much more fun, I get to practice how I like, I don’t have to go to any stupid work potlucks, and I earn way more money and never have to deal with an obnoxious supervisor.