Your Essential Guide to Starting a Private Practice in EM-IM

Understanding the EM–IM Combined Path and Why It’s Uniquely Positioned for Private Practice

Emergency Medicine–Internal Medicine (EM IM combined) training offers a powerful, flexible platform from which to explore independent practice. While many graduates naturally move into academic roles, hospital employment, or ED director positions, a growing number are exploring starting a private practice—whether that means opening a medical practice focused on hospitalist work, urgent care, hybrid ED-obs units, or longitudinal outpatient care with access to acute services.

Before exploring business logistics, it’s essential to understand how your dual training shapes your options:

• Breadth of practice
  • EM gives you acute care, resuscitation, risk stratification, and procedural skills.
  • IM provides continuity of care, chronic disease management, and inpatient medicine competency.
• Settings where EM–IM shines
  • Observation units and short-stay acute care
  • Hospitalist and consult services
  • Urgent care centers and hybrid “acute primary care” models
  • Complex outpatient internal medicine clinics with on-site acute capabilities
• Strategic advantages for private practice
  • Ability to design a practice that spans acute and longitudinal care
  • Market differentiation: “We manage your emergencies and your chronic care under one umbrella”
  • Flexibility to contract with hospitals for ED/inpatient coverage while maintaining an outpatient panel

At the same time, you must balance the realities of private practice vs employment:

• Employment typically offers:
  • Predictable salary, benefits, and malpractice coverage
  • Less administrative and financial risk
  • Limited control over schedule, care models, and innovation
• Private practice offers:
  • Greater autonomy over scheduling, staffing, and clinical pathways
  • Potential for higher long-term earnings and equity in the business
  • Significant upfront work, financial risk, and ongoing management demands

Understanding these trade-offs early will shape whether you focus on:

• A pure outpatient internal medicine clinic with urgent access slots
• An urgent care / acute care clinic leveraging your EM skill set
• A hybrid model with outpatient clinics plus contracts for ED, observation unit, or hospitalist services
• A group practice or partnership aligned with a health system, but independently owned

The rest of this guide walks you step-by-step through opening a medical practice as an EM–IM physician, with practical examples and pitfalls to avoid.

---

Step 1: Clarify Your Practice Vision and Scope of Services

Opening medical practice doors without a clear clinical and business model is one of the most common mistakes physicians make. For EM–IM combined graduates, the challenge is often too many possibilities rather than too few.

Define Your Core Model

Start with three questions:

1. Who is your primary patient population?

   • Complex, multi-morbid adults needing longitudinal internal medicine care
   • Underserved populations with poor access to emergency and primary care
   • Working adults seeking same-day or after-hours urgent care
   • Hospitalized patients needing hospitalist or consult services

2. What level of acuity will you routinely manage?

   • Low–moderate acuity only (e.g., urgent care, stable chronic disease)
   • Moderate–high acuity with on-site monitoring and procedures (e.g., chest pain observation, IV therapy)
   • A blended model with clear triage protocols and EMS/hospital partnerships

3. How will patients access you?

   • Traditional clinic hours only
   • Extended evening/weekend hours
   • Virtual and in-person hybrid, with tele-triage for acute symptoms

From there, you can choose a primary structure:

Model A: Internal Medicine Practice with “Acute Access”

• Core: Traditional IM panel-based care
• EM leverage: Same-day acute slots, on-site urgent evaluation (EKG, minor procedures, IV fluids)
• Typical services:
  • Chronic disease management
  • Rapid evaluation of chest pain, shortness of breath, minor injuries with clear escalation pathways
  • Transitions-of-care clinics post-hospital discharge

This model is more familiar to payers and easier to credential but requires strong clinic workflow design.

Model B: Urgent Care / Acute Care Clinic with EM–IM Branding

• Core: Walk-in or same-day urgent care
• EM leverage: Strong emergency triage, risk stratification, and rapid workup
• IM leverage: Continuity option for frequent utilizers (“If you like our care, you can follow with us”)
• Typical services:
  • Management of minor injuries, infections, asthma/COPD exacerbations, chest pain rule-out pathways (where safe)
  • On-site imaging and lab partnerships
  • Occupational medicine or employer-focused contracts in some markets

Here, marketing and operations will look more like standard urgent care, with your EM–IM combined training as a differentiator.

Model C: Hybrid Outpatient Practice + Hospital Contracts

• Core: You or your group provide:
  • Outpatient IM services, plus
  • Hospitalist or ED coverage under contract with a hospital
• Advantages:
  • Diversified revenue streams (professional fees from hospital, outpatient billing, potential stipends)
  • Stronger relationship with local health systems
  • Opportunity to build observation unit or rapid access clinic models

This is one of the best strategic fits for EM–IM physicians but is more complex to negotiate and manage.

Define Clear Inclusion and Exclusion Criteria

Regardless of your model, define:

• Conditions you will routinely manage in the clinic
• Conditions that always trigger ED transfer or 911
• Procedures you will offer (e.g., I&D, joint injections, laceration repairs, bedside ultrasound, stress testing, IV meds)

Write these as formal clinical protocols early; they will influence:

• Space design and equipment needs
• Malpractice coverage and risk profile
• Staffing and training (e.g., nurses comfortable with IV pushes, ACLS, triage)

---

Step 2: Business Planning, Legal Structure, and Financing

Once your clinical model is sketched out, you need a solid business plan. Many EM–IM physicians underestimate this component because they are used to hospital-based systems handling logistics. In private practice, you are the system.

Choose a Legal Structure

Common options when starting a private practice include:

• Professional Limited Liability Company (PLLC) or Professional Corporation (PC)
  • Often required by state law for physician practices
  • Helps separate personal and business liabilities
• S-Corporation election (for tax treatment)
  • Often recommended for small practices after discussion with a CPA
• Partnership or Group Entity
  • Useful if starting with one or more co-founders or merging with existing groups

Action steps:

1. Consult a healthcare attorney in your state to:
   • Review state-specific rules on physician ownership
   • Draft or review bylaws, operating agreements, and buy-in/buy-out terms
2. Work with a CPA experienced in medical practices for:
   • Entity selection advice (PLLC vs PC vs LLC w/ special designation)
   • Tax planning and payroll structures

Develop a Lean but Realistic Business Plan

At minimum, your plan should cover:

• Market analysis:
  • Patient demographics (age, payor mix, disease burden)
  • Existing ED, urgent care, and internal medicine practices
  • Local hospital and health system strategies (are they expanding or consolidating?)
• Service lines and projected volumes:
  • Number of clinic visits per day (year 1 vs year 3)
  • Potential ED/hospital contracts (FTEs, shifts per month)
  • Ancillary services (stress tests, ultrasound, infusion, etc.)
• Revenue assumptions:
  • Payer mix: Medicare, Medicaid, commercial, self-pay
  • Expected reimbursement per visit and per procedure
  • Hospital stipend potential (for ED or hospitalist coverage)
• Expense projections:
  • Lease, build-out, equipment
  • Staffing (front desk, MAs, RNs/NPs, billers)
  • Malpractice, licensing, IT/EMR, marketing

When in doubt, be conservative. It is far safer to grow into profitability than to overextend and be forced to sell or close prematurely.

Financing Your Practice

Options include:

• Conventional bank loans
  • Often require a detailed business plan and personal guarantees
• Small Business Administration (SBA) loans
  • Longer terms, lower down payments, but more paperwork
• Lines of credit
  • Useful for smoothing cash flow variability in the first 1–3 years
• Private investors or partners
  • Be cautious: maintain physician control over clinical decision-making
• Personal savings
  • Reduces interest burden but increases personal financial risk

Create a 12–24 month cash flow plan, incorporating:

• Delayed reimbursements (you may not see robust revenue for 90–180 days)
• Credentialing lag with payers
• Marketing ramp-up period before panel is full

Practical tip: Many new owners underestimate how long it takes to get paid for the services you provide. Plan for at least 6 months of operating capital.

---

Step 3: Regulatory, Credentialing, and Risk Management Foundations

Emergency medicine internal medicine physicians are usually highly credentialed, but starting a private practice adds multiple layers of regulatory complexity.

Licensure and Credentialing

Ensure all the following are in place:

• State medical license (and any additional states if doing telemedicine)
• DEA registration and relevant state prescribing program enrollment
• Hospital privileges (if you’ll admit or cover inpatient/ED services)
• Payer enrollment:
  • Medicare and Medicaid
  • Major commercial insurers in your region
  • Workers’ compensation programs, if relevant

Credentialing can take 3–6 months (or longer). Start early, ideally before signing a lease if possible.

Malpractice Insurance

Malpractice needs are different for outpatient IM vs ED vs hospitalist work. As an EM–IM specialist with a hybrid practice, you should:

• Work with a broker who understands multi-setting practices
• Disclose all sites of practice: clinic, ED, inpatient/hospitalist, telehealth
• Clarify:
  • Occurrence vs claims-made policies
  • Tail coverage, especially if you’re leaving an employed ED group
  • Coverage for mid-levels or other clinicians you supervise

If you’re practicing in higher-acuity outpatient settings (e.g., on-site observation, IV meds, chest pain rule-out), ensure your coverage specifically acknowledges and covers these services.

Compliance, HIPAA, and Risk Management

Even if your practice is small, you must:

• Create a HIPAA compliance plan
  • Privacy policies
  • Staff training and annual refreshers
  • Business Associate Agreements (BAAs) with your EHR vendor, billing company, and other vendors
• Adopt OSHA and infection control policies appropriate to your services
• Implement clinical risk management:
  • Standardized triage protocols (especially if you accept urgent walk-ins)
  • Clear ED transfer policies and documentation
  • Regular chart audits (especially for chest pain, abdominal pain, high-risk complaints)

Your EM background is an asset here. Apply ED-style checklists and protocols to reduce error risk in the outpatient environment.

---

Step 4: Facility, Equipment, and Staffing for an EM–IM-Oriented Practice

Your physical environment should follow from your clinical model. An EM–IM hybrid practice often needs more capability than a standard IM clinic but less than a full ED.

Choosing a Location and Space

Key factors:

• Proximity to hospital/ED:
  • Helpful if you triage and transfer higher-risk patients
  • Makes collaboration and contract work easier
• Accessibility:
  • Public transport, parking, ADA-compliant access
  • Visibility from main roads if offering urgent care/walk-in services
• Size and layout:
  • Typical first clinic: 4–6 exam rooms, 1–2 procedure rooms, small lab area
  • Space for staff workroom, provider offices, clean/dirty utility

For an acute-oriented practice, consider:

• A dedicated triage/vitals area
• A small observation bay with recliners and monitoring capabilities
• Space for point-of-care ultrasound and basic emergency equipment

Equipment and Supplies

Beyond standard internal medicine clinic supplies, EM–IM practices often include:

• Point-of-care diagnostics:
  • EKG machine
  • Glucose, pregnancy tests, basic labs (CBC, chem panel, troponin if CLIA-certified and clinically appropriate)
• Emergency equipment:
  • Crash cart with AED/defibrillator
  • Airway equipment (BVM, oral/nasal airways)
  • ACLS drugs and protocols
• Procedure setups for:
  • I&D, laceration repairs, joint injections
  • Abscess drainage, foreign body removal, splinting
• Optional:
  • Point-of-care ultrasound (POCUS)
  • On-site X-ray (may require extra build-out and radiation permits)
  • Telemetry or continuous pulse oximetry/telemonitoring

Balance “nice to have” with “need to have.” Over-equipping can strain finances early; start with core capabilities that align with your defined scope.

Building Your Team

At minimum, you will need:

• Front desk / patient access staff
• Medical assistant(s) and/or nurse(s)
• Billing and coding expertise (either in-house or outsourced)
• Practice manager (may be part-time at first)

Additional clinical staff options:

• Nurse Practitioners (NPs) or Physician Assistants (PAs)
  • Help expand access while you focus on complex cases, hospital duties, or procedures
  • Require clear supervision protocols and standardized order sets
• Other EM–IM or single-boarded EM/IM colleagues
  • Ideal for building a group practice model and shared call coverage

Your ED experience with team leadership is a major asset here. Use established ED-style huddles, shift briefings, and debriefs to foster cohesive teamwork.

---

Step 5: Operations, Billing, and Growth Strategy

Once infrastructure is in place, your success hinges on daily operations and how effectively you manage revenue in a complex reimbursement environment.

Choosing an EHR and Practice Management System

Priorities for an EM–IM practice:

• Efficient urgent and chronic care documentation
• Integrated scheduling for:
  • Same-day/urgent visits
  • Routine follow-ups
  • Virtual visits (if offered)
• Strong billing, coding, and reporting tools
• Templates for:
  • High-risk acute complaints (chest pain, abdominal pain, shortness of breath)
  • Transitions-of-care visits
  • Chronic disease management

Consider systems specifically built for ambulatory care but flexible enough to capture higher-acuity encounters and procedures.

Billing, Coding, and Revenue Cycle

Whether you handle billing in-house or outsource, you must understand:

• E/M coding for:
  • Office/outpatient visits (new vs established)
  • Prolonged services, transitional care management, chronic care management
• Procedural coding for lacerations, abscess drainage, splints, POCUS, etc.
• Place of service and modifiers:
  • Especially relevant if you work in multiple settings (clinic, ED, hospital)

Track key metrics monthly:

• Days in accounts receivable (AR)
• Denial rates and most common denial reasons
• Payer mix and reimbursement trends
• Net collection rate

Your dual background also positions you well for value-based contracts over time (e.g., reducing ED utilization among your panel). But in year 1, focus first on mastering fee-for-service mechanics.

Scheduling and Clinical Workflow

Design clinic templates to reflect your practice identity:

• For an acute-access IM clinic:
  • Reserve blocks for same-day urgent slots
  • Balance chronic care follow-ups with acute visits
• For urgent care–heavy models:
  • Extended hours and clear “last patient check-in” policies
  • Staggered staffing to manage predictably busy times

Clinical workflows that are especially important:

• Front-end triage:
  • Train staff to identify red-flag symptoms and rapidly involve a clinician
  • For higher-acuity presentations, activate your ED transfer protocol early
• Test follow-up:
  • Robust system for critical lab and imaging results, including after-hours
• Care transitions:
  • When you discharge a patient from your practice to the ED or admit them, ensure follow-up communication and documentation

Marketing and Relationship-Building

Building volume is a major challenge in the first 1–3 years of independent practice.

Strategies that fit EM–IM combined physicians well:

• Educate local PCPs and specialists:
  • Position your clinic as a “rapid access” alternative to ED for appropriate cases
  • Offer to see their complex or high-utilizer patients for acute issues and then send back with recommendations
• Partner with hospitals:
  • Propose observation unit coverage, transitions-of-care clinics, or after-hours access to reduce ED crowding
• Community outreach:
  • Talks on recognizing emergency symptoms vs urgent symptoms
  • Employer-based educational campaigns or workplace clinics

Maintain a clear, patient-friendly message about what you do and when patients should go directly to the ED instead.

---

Private Practice vs Employment: Making the Right Choice for You

Many EM–IM trainees wrestle with private practice vs employment decisions throughout residency and early career. Some guiding considerations:

When Private Practice May Be a Great Fit

• You have a strong desire for autonomy in clinical practice design.
• You are comfortable with (or eager to learn) business, leadership, and operations.
• You are willing to accept financial risk and variable income initially for potentially higher long-term reward.
• You want to experiment with innovative models blending emergency medicine internal medicine practice, such as:
  • Chest pain clinics
  • High-acuity urgent care with POCUS and on-site IV therapy
  • Longitudinal care for high ED utilizers

When Employment May Be Better (At Least Initially)

• You value predictable income and less non-clinical responsibility.
• You’re early in career and want to build clinical confidence before assuming business risk.
• You’re already in a high-earning, stable ED or hospitalist role and feel satisfied with the structure.

Many physicians choose a hybrid path:

• Start employed for several years to build savings, understand local markets, make contacts, and learn systems management.
• Then move to starting a private practice when they feel ready, often maintaining part-time ED or hospitalist shifts for stable income during ramp-up.

---

FAQs: Starting a Private Practice in Emergency Medicine–Internal Medicine

1. Can EM–IM trained physicians successfully run an outpatient-focused private practice?

Yes. EM–IM combined training gives you a strong foundation for both acute and chronic care. Many EM–IM physicians run:

• Traditional internal medicine clinics with robust same-day access
• Urgent care centers that also provide longitudinal follow-up
• Hybrid models with outpatient clinics and hospitalist/ED contracts

The key is to clearly define your practice scope, create safe triage and transfer protocols, and align your staffing and space with that scope.

2. Do I need prior business or MBA training to start a private practice?

Formal business training helps but is not mandatory. What is essential is:

• Willingness to learn fundamentals of finance, contracts, and HR
• Partnering with experts:
  • Healthcare attorney
  • Medical-practice-savvy CPA
  • Revenue cycle/billing specialists
• Being realistic about your knowledge gaps and investing in practice management support as you grow

Many EM–IM physicians start small, learn iteratively, and build more sophisticated systems over time.

3. How risky is it financially to open a medical practice in today’s environment?

There is real risk, especially with:

• Rising overhead (rent, staffing, malpractice)
• Payer consolidation and complex reimbursement
• Competition from health-system-owned clinics and urgent cares

However, EM–IM physicians can mitigate risk by:

• Starting lean (modest space, limited but targeted equipment)
• Leveraging part-time ED or hospitalist work for stable income initially
• Choosing locations with clear unmet need or underserved populations
• Building hospital or employer contracts to create baseline revenue

A sound, conservative business plan and adequate initial capital (often 6–12 months of operating expenses) are critical.

4. How can I combine ED/hospital work with my private practice without burning out?

Strategies include:

• Setting strict boundaries on your maximum total clinical hours (e.g., 0.5–0.7 FTE in ED/hospital + 0.3–0.5 FTE clinic in early stages)
• Hiring or partnering with other clinicians (NPs, PAs, physicians) as the clinic grows
• Using your EM experience with shift work to design sustainable schedules
• Delegating non-clinical tasks to a strong practice manager as soon as feasible

EM–IM training prepares you well for variety, but sustainable pacing and intentional scheduling are essential to avoid burnout.

---

Starting a private practice in Emergency Medicine–Internal Medicine is challenging but offers unmatched flexibility, creativity, and impact. By aligning your dual training with a clear practice model, robust business planning, and disciplined operations, you can build a practice that truly reflects the unique strengths of EM–IM combined training—caring for patients across the full spectrum of acuity, on your own terms.