Avoiding Cashflow Issues
and Expanding Market Presence
for your New Anesthesia Practice

Doctor surrounded by new anesthesia practice staff

Walking Away From The Punch Clock

Starting a new anesthesia practice can be both a liberating and nerve-racking experience. With the No Surprises Act now in play and insurance plans widely refusing to negotiate new contracts with hospital-based specialists, the landscape has dramatically changed.

This isn’t to say there aren’t amble opportunities for new private practice anesthesia groups, but rather, that the rules of engagement have changed. This article will discuss strategies to help mitigate cashflow issues during your start-up and expand your presence in the market.

Managed Care Contracting

It’s not hard to see how the insurance industry gained a huge advantage in the passing of The No Surprises Act. Legislation originally slated to protect patients from high out-of-network balances ended up creating a system where insurers could pay significantly less to non-par groups.

Prior to the passage of this law, many payors would end up remitting 100% of the billed charge to out-of-network anesthesia providers, who worked with in-network surgeons and facilities.

After 1/1/22, these same anesthesia providers are now forced to accept the insurer’s median contracted rate (which is unpublished), or go through an Independent Dispute Resolution (IDR) process, if they seek higher payment.

The takeaway here is that established practices with existing contracts have a path to higher reimbursement, especially if they have automatic escalator clauses built into their agreements. That being said, payors are now supposed to adjudicate all out-of-network claims within 30 days of receipt and remit payment directly to the practice (as opposed to the patient), which benefits the non-par anesthesia group.

The bottom line is that you may have to accept a lower unit rate than your in-network colleagues. Even if you’re able to secure a contract, the rate offered will most likely be less than before The No Surprises Act came on the horizon. Since insurance plans already know what they’ll have to pay you as “out of network”, any proposal is going to reflect that number as a starting point. Before your negotiation begins, it will be prudent to compare your average payment per unit by insurance plan, to ensure that any contract rate offered generously exceeds this number. 

Lastly, if your facility administrator requires you to be in-network with all major payors, ask for assistance in getting to the negotiation table with the contract reps. This leverage may be more valuable than you think, as the facility and surgeons have a vested interest in facilitating your in-network status with their larger insurance plans.

Lead Time for Billing Company

Most new anesthesia groups choose to outsource their professional billing, so they can focus on growing the business and contain overhead costs. As with any billing start-up, it’s best
to begin discussions with a potential vendor at least 60-90 days before you begin providing clinical services. This allows time for provider enrollment with certain insurance plans, which is a prerequisite for claim payments.

If you start providing clinical services without the proper lead time for your biller, collections will be significantly delayed. So, unless you have the financial means to wait it out, get your billing transition started well ahead of time.

Business Bank Account and Lock Box

Insurance plans require claim payments to go directly into the practice’s bank account (and not the billing company’s). For this reason, you’ll want to set up a business account prior to your new group providing clinical services. In addition, most billing companies require that you have a lock box connected to your bank account. This allows the bank to scan all checks/correspondence and convert to a digital format, for the biller’s payment posting function. Lock boxes can take weeks or even months for banks to set up, so start the process early to avoid payment delays.

New Providers and Staffing Locations

As you start obtaining service contracts for new sites, you’ll invariably need to start hiring more clinical staff. Similar to provider enrollment, make sure that your billing agent is kept apprised of all new provider and service location start dates. Don’t wait to tell your billing company until after the fact, as this will simply slow down your collections.

Documentation Training

Another area often overlooked by new practices is provider documentation training. Since such practices are typically comprised of providers with varying work and charting experience, it’s best to conduct an initial baseline training session, to promote documentation consistency and prevent pended cases. You can also record these sessions for future providers to review.

Topics should include start/stop charting, discontinuous time for spinals in pre-op, MAC vs. General designations, post-op pain block with USG charting requirements, surgical procedure specificity, post-op diagnoses, and relief time, to name a few.

Hire an Admin

The biggest error that new anesthesia practices can make is thinking that clinicians will have the time to manage the practice by themselves. Hiring a good administrator to handle the day-to-day non-clinical business is crucial to your success.

This individual will act as the liaison between your practice and the billing agent, facilities, and even patients. If you’re lucky, you may even find one with managed care contracting experience. Set aside room in your budget for a detail-oriented multitasker, preferably someone who has worked in anesthesia practice management before.

Establish a Social Media Presence

The best way to market your new practice and discover anesthesia coverage opportunities is through Social Media. Hiring a good marketing firm doesn’t have to be expensive and can pay for itself with one new contract. Since no one knows all of the staffing opportunities available on any given day, consistently posting quality content promoting your practice (on sites like LinkedIn) will let facility administrators know that you’re available and help to expand your coverage area beyond a regional presence.

ASC Staffing Opportunities

The national shortage of anesthesiologists and CRNAs has been well chronicled for quite some time. Since the business of medicine operates within the same “supply and demand” paradigm as other industries, it can create opportunity for entrepreneurial clinicians.

With hospital coverage being a priority for most existing practices, if there’s a shortage of anesthesia staff, it’s the Ambulatory Surgery Center (ASC) contracts that will be dropped first. Combine this with the explosive ASC growth for Orthopedics and Medicare’s loosening of the Inpatient Only list, and you have high yielding anesthetics in need of clinical coverage. Even the Eye and GI service lines can be profitable, as long as you have income guarantees in place, to protect against inefficient OR utilization and/or a sub-par payor mix.


As with any new business endeavor, attention to detail, proper planning, and delegating tasks to trustworthy partners, are all keys to your success. As providers and facilities become more disillusioned with Corporate Medicine, we expect the allure of independent anesthesia practices to come full circle. Even with the No Surprises Act in play, there’s still plenty of room for these practices in 2022, and certainly lots of opportunity.

Hal Nelson, Vice President Anesthesiology Services

Hal Nelson, CANPC
has 30 years experience on both the payer and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national billing companies. He has also taught the CPC coding curriculum collegiately in Atlanta. His broad based experience ensures that MSN clients will have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins. 

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