What to do in the 3 months before you start your successful plastic surgery practice
Part two of a two-part series

Last month, I discussed the steps you should take to open a plastic surgery practice, from 1 year to 4 months before the opening. Now, I will detail the crucial final months before the big day.

3 Months Before Opening
After you obtain hospital privileges, begin applying to become a participating provider for third-party payors (insurance companies). You will already have obtained your federal tax identification number to enable you to do this.

One way to determine which payors to apply to is to ask other physicians in the area about the companies with which they participate. Be sure to get a sample fee schedule so that you know what you might be getting into.

Make several copies of the following documents so you can have them handy to send with the applications: medical school, general surgery, and plastic surgery residency graduation certificates; curriculum vitae; malpractice insurance cover letter and policy; US Drug Enforcement Administration (DEA) and medical licenses; and your plastic surgery boards applicability letter.

Begin the marketing process for your practice. Call local newspapers and magazines to request their media kits so that you can decide where to place new-office announcement ads. Be sure to ask local newspapers if they would be willing to write an article about your new practice if you advertise with them. The issue of advertising is a controversial one, and it has been covered in detail elsewhere, but make sure you do not break any of the rules regarding advertising set forth by the American Board of Plastic Surgery and the American Society of Plastic Surgeons (ASPS).

Check into various skin care programs you may want to offer in your practice. Try out the products yourself and have others try them for you. If you are like me, this gives you time to clear your complexion before you start your practice.

Look into private or freestanding surgical centers at which to perform aesthetic surgery. Most of them will be difficult to find in the phone book, so ask vendors—such as breast implant reps—or other plastic surgeons to determine where a good place to operate would be. Compare the facilities, and ask for their hourly rates.

Continue to focus on the buildout of your suite—this usually takes at least 2 months. If the space is already built out, then you may only need to perform leasehold improvements (smaller changes to an already-built suite) to get the suite exactly how you want it.

After the architect makes the initial drawings for your suite, he or she will likely need power specifications, such as for your electric-powered chair, laser, and so forth. If the suite is already built out, then this may not be as much of a worry.

After the plans are finalized, they go to the city for approval. Depending on the city you will be practicing in, it may take from several weeks to months for the plans to be approved.

Once the plans are approved by the city, the contractor can proceed with building out your suite. Contractors are notoriously inefficient, so be sure to be on top of them to avoid delays. Consider taking out a buildout bond, which helps insure you against buildouts that are overly delayed.

You will likely need to make the following contacts before completing the buildout:

• Telephone service. Contact the local telephone company and inform it that you will be setting up multiple phone lines. I recommend at least two lines for the office phone system and one line dedicated to fax and credit card processing. 

• Telephone equipment and setup. You will probably have to pay for this; it won’t be included in your buildout allowance. For five or six phones and three lines, I received estimates from $1,800 to $5,000 for setup.

• Music. If you want to pipe in soothing music to patients and staff, it might be a good idea to get this hard-wired prior to putting in the ceilings and walls. You can do it yourself and hook it up to a portable media player or stereo, or you can call a company like Muzak to do it for you.

• Cable or satellite television and Internet service. Contact your local cable or satellite company to install this with your buildout. Ideally, it will not cost you extra, but it will likely require a commitment of several years for the company to install the cable hookups or satellite dishes. Be aware that commercial cable  or satellite, and Internet, service is more expensive than residential.

• Start looking to lease or buy office equipment. Remember, you will likely need at least one procedure chair (at least semipowered), but you can go with less-costly examining-room benches for the rest. Other things you will need: computers, a copy machine, a fax machine, a typewriter, a refrigerator, a coffee maker, and a microwave.

Buy laser—not ink-jet—printers and copiers. They will be more expensive initially, but in the long run they will save you money on ink cartridges. Look into buying plans such as those with discount office-supply chains to try to get these items at a reduced cost.

• Look into buying or leasing furniture for the office. Try to get nice furniture for your waiting room and consultation room, if you can afford it. Don’t spend as much on areas that the patients will not see or will see only after they have had surgery (for example, the employee break room or postoperative exam rooms). It may take a month or longer to get furniture delivered, so check into this far in advance.

• Turn on the following utilities: electricity, gas, and water.

2 Months Before Opening
Have your stationery made. You will need the following at the minimum:
• Letterhead on good-quality paper with a watermark;
• Envelopes on good-quality paper;
• Business cards;
• Appointment cards (these can be inexpensive);
• Prescription pads; and
• Brochures, if desired.

Talk with your accountant about how you want to set up payroll. You can do it yourself, hire an office manager to do it, or contract with a payroll specialty company. After I consulted with my accountant, he recommended that I save myself the time, hassles, and potential penalties for any mistakes I could make by hiring a payroll-specialty company. The company offered to do all my payroll (all I would give them are the hours worked and the hourly wage), calculate my tax deductions (for social security, state, and federal taxes), and do the year-end W-2s. It would also take responsibility for any mistakes and therefore would pay any penalties.

Set up credit-card processing for your practice. It will cost you some money to get started because you will have to buy or lease the credit-card processing machine. Check with local banks and your state medical society to compare rates. You should expect to pay between 1.6% and 2.5% per transaction, as well as other fees. You will need to apply for the processing, and the application process can take several weeks.

Obtain Current Procedural Technology (CPT) and International Classification of Diseases (ICD-9) handbooks—and study them! The ASPS publishes the excellent CPT Corner Notebook1 that I strongly recommend. In addition, obtain the handbooks published by the American Medical Association each year to keep up to date on all codes.

Order white coats with your name and practice name on them—or at least “plastic surgery.” It’s time to stop acting and looking like a resident! Be sure to get them extrastarched at the dry cleaners.

Your practice will need workers’ compensation, personal property, and other insurance. Contact your state medical society or colleagues in town for references. Don’t bother buying workers’ comp for yourself if you already have a disability policy .

Consider billing options. If you will be doing a substantial amount of insurance work, decide who will do the billing for you. Remember that billing is a continual process, and you don’t get paid right away!

Insurance companies can misplace your paperwork, refuse to pay, or simply drag their heels. Someone needs to keep track of invoices for payments that have not returned. You can do it yourself, which will take considerable time, or have your office staff do it. Otherwise, you can pay 5% to 7% of your receipts to an outside source to do it for you. I would recommend keeping track of any aesthetic surgery funds yourself at first.

Look into dictation equipment. You can dictate in many ways:
• dictate onto minitapes and send them to a company to print the dictation;

• call into a dictation service (some hospitals have dictation systems you can use for hospital-related dictations);

• buy a computer-based voice-recognition system;

• go the cheapest route by typing your own dictations and changing them as needed for each patient. I have a folder on my computer with standard office-procedure reports (one for laceration repair, one for skin-lesion excision, and so on) that I customize to each patient.

Be sure to inform the state medical licensing board and the DEA about your new address of practice.

Call the various reps in the area to be sure that you have enough supplies to start with. Some companies supply virtually everything you need for your office (such as exam chairs, 4x4s, needle drivers, waste-baskets, gowns). They will usually ship with no charge.

Also, be sure to call the breast-implant rep in your area to get started on new-to-practice discounts. Other vendors to consider include injectables and solid-implant companies. If you will be performing hand surgery, make sure you have all the splints you may need.

Order magazines for the office. Ask your local medical society or check the Internet for companies that offer discounts for professional waiting rooms.

Write an employee manual. This is a manual that all employees receive. It explains the policies of the office, including benefits, vacation time, and codes of conduct. It is a major undertaking to write it from scratch, so I would recommend asking one of your colleagues for a copy of theirs to modify and make your own.

It is helpful to have this written before hiring employees. Have them sign a letter acknowledging that they have received and read it.

Write or call the state department of labor for state employment regulations and wage and hour information. Most states require certain notices (such as minimum wage and discrimination) to be posted where all employees will see them.

Call the city clerk and county clerk to determine if occupational licenses are necessary.

1 Month Before Opening
Sign up for a financing plan for aesthetic patients. You will need the finance company’s brochures to give to patients. There should be no cost for you to join, but remember that the finance company normally charges from 2% to 5% of your surgeon’s fee for each surgery you perform under its plan. It is usually forbidden to pass these costs off onto the patients.

Determine your fee schedule. First, work on your aesthetic fee schedule. There are many resources for this, including the ASPS for its average surgeon’s fees. You will also need to determine a fee schedule for reconstructive surgeries. One easy way to do this is to add a set percentage to the Medicare fee schedule.

Begin organizing all of your office forms, including patient-consent forms, medical-history forms, and postoperative instruction sheets. The ASPS has numerous resources for this, such as the Patient Consultation Resource Book.2 It contains a plethora of medical releases and consent forms, all specific for each procedure.

The Office Management Handbook,3 also available from the ASPS, contains a guide for business practices and templates for many of the other office forms you will need. Both of these resource books were extremely helpful to me in that they saved me time and improved the organization of my practice startup.

Begin looking for office help. Initially you will need only one employee, who can function as both receptionist and patient coordinator. You will function as office manager for the time being and can groom this first employee into the spot.

Talk to people in your area, call your hospital staffing office, or place a local ad. Do not place your office or home number in the ad, and consider using a fax number instead. Better yet, use an e-mail address so you can weed out the non–computer- literate people you probably wouldn’t want.

Set up interviews with the five to 10 most eligible and impressive candidates. Have them fill out an application form and bring a list of references.

It’s good before the interviews to have an idea of benefits you may give to employees. Also, consider a probationary period of 1 to 3 months, and ask employees to sign an at-will agreement. At-will employees may leave at any time without notice, but they can also be let go at any time without notice. Ask your attorney for more details.

Set up an answering service for your phone line. Call local physicians’ offices or look in the yellow pages for more information about this.

Begin answering your own phone and taking appointments. If you have a spouse or family member who is willing to do so, have him or her answer the phone until your practice is up and running.

There is usually a minimal cost to forward your office’s phone number to a home phone or cell phone. This is extremely helpful, especially if your office isn’t built out yet. I had my number forwarded to my cell phone and often answered the calls myself because I had no employees and my wife was working.

Buy a scheduling book with daily and weekly schedules. You may consider a computer-based scheduler, but these can be costly ($1,000 for simple programs, and up to $8,000 for extensive ones). An 8½ x 11 scheduling book bought for $20 from an office-supply store usually works well to start with, and you can carry it with you to make appointments.

Obtain and customize the Patient Inquiry Manual4 from the ASPS. This is a resource guide to teach your staff about the surgeries that you do so they can be educated when they talk with prospective patients. It can be completely customized to your practice, and it is a perfect reference for your employees to learn about your plastic surgery procedures.

Arrange for janitorial services for your suite. To save money, you will probably not need them to clean your suite every day. Usually, two or times per week is sufficient for a small practice.

If you are planning on performing hand surgery, look into therapy and x-ray options in the area. Take the time to stop by each facility to make sure it fits your expectations and to collect brochures with maps for your patients.

Adopt universal standards for blood-borne pathogens. Make sure your office follows Occupational Safety and Health Administration (OSHA) rules and regulations. Contact the appropriate OSHA agency with questions.

Make sure your office is compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I recommend obtaining the HIPAA Privacy Manual: A How-To Guide for Your Medical Practice,5 available for purchase from the ASPS. This contains everything you need to know about setting up for HIPAA compliance and office forms.

Frame your diplomas and any publications for placement in your waiting area, consultation room, or office. Be sure to place them in areas where patients can see them so they can be impressed by your credentials. Even though you are new to practice, this should help reassure them that you are a well-trained and competent surgeon.

1 Day Before Opening
Congratulations on starting your own plastic surgery practice! Go out with your significant other for a nice dinner tonight and thank him or her for supporting you in your pursuit of such a difficult, yet rewarding career. Good luck!

Anthony Youn, MD, is a board-certified plastic surgeon and founder of The Hills Plastic Surgery and Laser Centre in Rochester Hills, Mich. He can be reached at (248) 650-1900 or via his Web site, www.beverlyhillsbeauty.com.

References
1. APSP/PSEF Resource Catalogue. CPT Corner Notebook. Available at: www.plasticsurgery.org/resource_catalogue/ list-items.cfm?vmgid=344&bmarketdesc=n. Accessed October 24, 2006.

2. APSP/PSEF Resource Catalogue. Patient Consultation Resource Book. Available at: www.plasticsurgery.org/resource_ catalogue/item-detail.cfm?vproductid=2407-11&vdetail=yes. Accessed October 24, 2006.

3. APSP/PSEF Resource Catalogue. Office Management Handbook CD-ROM. Available at: www.plasticsurgery.org/resource_catalogue/list-items.cfm?vmgid=290& bmarketdesc=n. Accessed October 24, 2006.

4. APSP/PSEF Resource Catalogue. Patient Inquiry Manual. Available at: www.plasticsurgery.org/resource_catalogue/list-items.cfm?vmgid=356&bmarketdesc=n. Accessed October 24, 2006.

5. APSP/PSEF Resource Catalogue. HIPAA Privacy Manual: A How-To Guide for Your Medical Practice. Available at: www.plasticsurgery.org/resource_catalogue/item-detail.cfm?vproductid=3360-00&vdetail=yes. Accessed October 24, 2006.

On The Web
To read part 1 of this series, go to the November issue of PSP at www.PlasticSurgeryProductsOnline.com and click on “Archives.”