Starting a Private Practice in Emergency Medicine: Your Essential Guide

Understanding What “Private Practice” Means in Emergency Medicine

“Starting a private practice in emergency medicine” doesn’t look like opening a typical office-based clinic. Emergency physicians practice in high-acuity, unscheduled care environments—usually emergency departments (EDs), free‑standing emergency centers, or urgent care facilities.

In this context, a “private practice” generally means:

• You or your group contract with a hospital or health system to staff and manage an ED (independent group practice), or
• You own or co-own a free‑standing emergency department or hybrid ED/urgent care, or
• You build a multi-site urgent care network with EM-level capabilities, staying within urgent/emergent unscheduled care.

Those models contrast with:

• Employed model: You are employed by a hospital, academic center, or large national group; they own the contract, set the schedule, and control most business decisions.
• Independent/private practice model: You hold equity and decision-making authority. Revenue flows to the practice, which then pays you (salary, bonus, profit share).

Because the EM match pipeline increasingly funnels residents into large national/health-system employers, independent practice has become less common but still exists—especially in smaller markets, free‑standing EDs, and urgent care networks. Understanding where you fit on the spectrum of private practice vs employment is crucial before you design a path.

Key takeaway: In EM, “starting a private practice” usually means building or joining a physician-owned group that contracts with facilities or runs its own emergency/urgent care centers, not opening a traditional appointment-based clinic.

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Step 1: Prepare During Residency and Early Career

If you’re still in or near training, you can dramatically increase your odds of success later by being intentional now.

Build a Strong Clinical Foundation

Even as you think like an entrepreneur, your credibility will rest on clinical excellence:

• Seek rotations with high volume and high acuity to build speed and accuracy.
• Volunteer for throughput and flow-focused QI projects; these skills matter when negotiating with hospitals.
• Learn to handle ED operations challenges: boarding, staffing constraints, fast track vs main ED, patient satisfaction.

Example: Become the resident leader on a project to decrease “door-to-doc” time. That operational experience is directly transferable to future ED management and contract negotiations.

Learn the Business of Emergency Medicine

Most residencies barely touch on business topics. You’ll want to fill those gaps:

• Attend ACEP/AAEM/RSA business and practice management tracks at national conferences.
• Read about:
  • ED billing and coding (ED E/M levels, procedures, critical care time)
  • Payer mix, RVUs, and compensation models
  • Value-based metrics (readmissions, LWBS, left before treatment complete)
• Find a mentor in an independent EM group, not only academic or corporate settings.

Ask:

• How are they paid by hospitals (stipend, collections, hybrid)?
• How are physician partners compensated and promoted?
• What are their payer mix and collection rates?

Clarify Your Career Vision

Before you commit to starting a private practice, be explicit about what you actually want:

• Do you want ownership and long-term equity, or are you mostly chasing higher immediate income?
• Do you prefer urban volume with complex cases, or a smaller community hospital where contracts may be more accessible?
• How much risk can you tolerate—financially and emotionally?

Write out your 5–7 year goals:

• Income range
• Lifestyle (shifts/month, nights, holidays)
• Geographic preferences
• Academic vs purely clinical vs mixed clinical-business roles
• Degree of control over operations

This written vision will guide your choices when you compare private practice vs employment options and decide whether employment is a step toward independent practice (e.g., learning operations at a community hospital) or a long‑term fit.

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Step 2: Choosing a Practice Model in Emergency Medicine

There are several viable structures for “opening medical practice” in EM. Each comes with different capital requirements, regulatory burdens, and risk.

Model 1: Independent Group Contracting with Hospitals

Overview: You form a physician-owned professional corporation or LLC that contracts with one or more hospitals to provide ED staffing and management.

Advantages:

• Lower initial capital than building a facility.
• Direct relationship with hospital leadership.
• Ability to negotiate stipends, metrics, and staffing.
• Equity and profit potential from group growth and multiple contracts.

Challenges:

• Intense competition with national EM groups.
• Need for strong group governance and fairness (partnership track, transparency).
• Heavy dependence on contract renewal; one lost contract can be catastrophic.

Typical pathway:

1. Gain experience as staff in a community ED.
2. Identify a hospital dissatisfied with current coverage (turnover, metrics, costs).
3. Assemble a core group of reliable EM physicians.
4. Propose a physician-owned solution emphasizing:
   • Stable local leadership
   • Quality metrics (door-to-doc, throughput, satisfaction scores)
   • Cost transparency
5. Negotiate a professional services agreement (PSA):
   • How your group will be paid (collections, stipend, or both).
   • Expectations and metrics.
   • Contract term and termination clauses.

Model 2: Free‑Standing Emergency Department (FSED)

Overview: You own or co-own a facility licensed as an ED, typically open 24/7, offering imaging, labs, and complex care short of inpatient admission.

Advantages:

• High charges per visit; can be profitable in select markets.
• Full control of operations, staffing, and culture.
• Opportunity to design patient experience from scratch.

Challenges:

• Very high startup capital (real estate, build-out, equipment).
• Complex regulatory requirements (state licensing, facility standards).
• Payer scrutiny; some insurers restrict reimbursement for FSEDs.
• Need robust community awareness and referral networks.

This model is usually pursued by experienced physicians with capital partners, not recent graduates. However, you can aim toward this long-term while initially working in other settings.

Model 3: Hybrid Urgent Care / Emergency Medicine Centers

Overview: You operate facilities that primarily function as urgent cares but are staffed by EM-trained physicians and capable of higher-acuity care than typical retail clinics.

Advantages:

• Lower regulatory burden than full EDs in many states.
• Lower capital requirements than hospital-based EDs or FSEDs.
• Growing demand for convenient, after-hours unscheduled care.
• More control over payer mix (can negotiate urgent care vs ED rates).

Challenges:

• Lower reimbursement than hospital EDs for similar work.
• Intense competition from urgent care chains and health systems.
• Requires strong local market analysis to avoid oversaturation.

Model 4: Tele-emergency Medicine

Overview: You provide EM expertise remotely to smaller hospitals, micro-hospitals, critical access facilities, or urgent cares via telehealth platforms.

Advantages:

• Lower capital and facility overhead.
• Geographic flexibility.
• Attractive to rural facilities that can’t staff full in-house EM.

Challenges:

• Reimbursement variability by payer and state.
• Technology and malpractice considerations.
• Perceived value: hospitals must be convinced that remote EM coverage improves quality and reduces transfers.

Choosing a Model: Key Questions

• What capital can you realistically access (savings, partners, loans)?
• How saturated is your target market with EDs/urgent cares?
• Are there hospitals seeking change in ED coverage?
• Do you have partners with complementary skills (operations, finance, marketing)?

Your answers will guide whether you start with contracting as a group, pursue facility ownership, or build a hybrid/telehealth model.

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Step 3: Legal, Financial, and Regulatory Foundations

Once you’ve chosen a model, it’s time to move from concept to structure.

Forming the Right Entity

Work with a healthcare attorney and accountant familiar with your state’s corporate practice of medicine (CPOM) laws. Common structures:

• Professional Corporation (PC/PA/PLLC) for physician ownership.
• Management Services Organization (MSO) to handle non-clinical operations (billing, HR, marketing), especially in CPOM states.
• Operating agreements that clearly define:
  • Ownership percentages
  • Capital contributions
  • How new partners are added (buy‑ins, vesting)
  • Decision-making processes and voting rights
  • Exit provisions and buy‑out formulas

Actionable tip: Do not recycle a generic LLC template. EM-specific realities (malpractice exposure, on‑call, shifts) require tailored agreements.

Licensing, Credentialing, and Privileging

Depending on your model, you may need:

• Facility licenses (for FSEDs, urgent cares) under state rules.
• CLIA certification for in-house labs.
• Imaging certifications (e.g., ACR accreditation for CT).
• Hospital medical staff privileges for each physician if contracting with hospitals.
• Payer credentialing with Medicare, Medicaid, and commercial insurers.

Build a credentialing checklist for every provider:

• State license(s)
• DEA, controlled substance registration
• Board certification or eligibility
• NPDB query
• Malpractice history

Assign or contract a credentialing specialist early; payer enrollment delays can cripple cash flow.

Malpractice Coverage

Emergency medicine is inherently high-risk from a malpractice standpoint.

Key decisions:

• Claims-made vs occurrence policies
• Adequate limits (commonly $1M/$3M or higher, depending on state)
• Tail coverage responsibilities when:
  • A physician leaves the group
  • A hospital contract ends
  • The group is sold or merged

Spell out in your operating agreement who pays for tail in different scenarios. Many internal disputes among EM groups revolve around this point.

Compliance and Risk Management

Regulatory compliance is not optional:

• EMTALA (for hospital-based EDs and FSEDs attached to hospitals)
• HIPAA and state privacy laws
• Stark and Anti‑Kickback regulations (especially for ownership in imaging or ancillary services)
• OSHA and workplace safety standards

Develop written policies for:

• Triage and acuity determination
• Transfer and refusal of care
• Documentation standards
• Controlled substance prescribing
• Incident and adverse event reporting

A proactive compliance culture protects both your license and your future ability to expand or sell the practice.

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Step 4: Financial Planning and Revenue Cycle in EM Private Practice

Cash flow can make or break a new EM practice. EM billing is complex, and revenue often lags months behind service.

Startup Budget and Capital Needs

Your initial budget will vary by model, but typical line items include:

• Legal and accounting fees
• Consulting (business planning, compliance)
• Malpractice insurance (down payment)
• Credentialing and payer enrollment costs
• Staffing and HR setup (recruiter fees, HR software)
• Billing and coding infrastructure or vendor setup
• IT systems (EHR, scheduling, telehealth platforms, secure messaging)
• Marketing and community outreach
• Facility costs (rent, build-out, equipment, supplies) for FSEDs/urgent cares

Create 12–24 month projections, including:

• Expected patient volumes (conservatively estimated)
• Average revenue per visit by payer class
• Days in accounts receivable (AR) assumptions
• Fixed vs variable expenses
• Cash reserves needed to cover 3–6 months of operating expenses

Understanding EM Revenue Streams

Emergency medicine revenue reflects:

• Professional fees (physician and APP services)
• Facility fees (hospitals or FSEDs, if you own or lease them)
• Ancillary services (imaging, labs) if under your control

Key billing concepts:

• Evaluation and Management (E/M) levels (99281–99285 for ED)
• Procedural codes (laceration repairs, reductions, intubations, etc.)
• Critical care billing principles
• Proper documentation supporting acuity and complexity

Misunderstanding or undercoding common EM procedures can leave substantial money uncollected.

Choosing a Billing and Coding Solution

You can:

• Build an in-house billing team (requires scale and expertise), or
• Contract with a specialized EM billing company.

Evaluate billing companies on:

• EM-specific experience and references
• Denial rates and appeals processes
• Transparency of reporting (collection percentages, RVUs per provider, payer breakdowns)
• Integration with your EHR
• Fee structure (typically 4–8% of collections)

Actionable tip: Demand detailed monthly dashboards showing:

• Collections per visit and per RVU
• Payer mix and denial trends
• Coding distributions by E/M level (compare to benchmarks)

Payer Mix and Contracting

Your local payer mix will strongly affect your financial viability:

• Commercial insurance plans
• Medicare
• Medicaid
• Uninsured/Self-pay

Conduct a market analysis:

• What proportion of ED patients in your area are uninsured?
• Which commercial payers dominate?
• Are there opportunities to negotiate favorable rates based on coverage gaps or quality metrics?

In some communities, hospital stipends are essential to offset low payer mix. Your pitch to hospitals should emphasize:

• How your group will improve throughput and satisfaction, reducing LWBS and diversion.
• How you will manage staffing more efficiently.
• Quality metrics and documentation that support payer negotiations.

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Step 5: Building Your Emergency Medicine Practice Team and Culture

Even the best strategy fails without the right people.

Recruiting Physicians and Advanced Practice Providers (APPs)

Define your staffing model:

• Number of EM-trained physicians vs APPs per shift
• Supervision ratios
• Coverage of nights, weekends, holidays

Recruit using:

• EM residency alumni networks
• ACEP/AAEM job boards
• Direct outreach to residents nearing the end of training, especially those recently through the EM match who are interested in private practice

Be transparent about:

• Compensation model (salary, RVU-based, hybrid, bonus)
• Partnership track (timeline, buy-in, governance rights)
• Expectations for shifts, committees, and admin work
• Non-compete clauses and geographic restrictions

Example: A new group might offer:

• Base salary + RVU bonus with a clear 2–3 year partnership track.
• Defined buy-in formula based on trailing 12-month financials.
• Protected admin time for those taking on scheduling, QI, or billing oversight roles.

Nursing, Tech, and Administrative Staff

Your culture will be strongly shaped by non-physician staff:

• ED nurses and charge nurses
• Techs and paramedics
• Registration staff
• Scribes (if used)
• Office manager/practice administrator

Invest in:

• Training programs that align with your clinical standards.
• Regular multidisciplinary meetings to address flow, safety, and communication.
• Recognition programs and feedback mechanisms.

Leadership and Governance

Create a governance structure that allows nimble decision-making without alienating junior partners:

• Medical Director (clinical oversight, hospital liaison)
• Director of Operations or Practice Administrator
• Committee leads for:
  • Quality and patient safety
  • Scheduling and staffing
  • IT/EHR and workflow optimization
  • Finance and contracting

Define how major decisions are made:

• What requires a simple majority vs supermajority?
• Who can sign contracts and hire/fire?
• How are profits distributed and reserves allocated?

This structure will influence whether your private practice feels like a true physician-led organization or a chaotic collection of independent contractors.

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Step 6: Growth, Sustainability, and Strategic Decisions

Once you’ve launched, you need to think several years ahead.

Measuring Success

Track key performance indicators (KPIs):

Clinical/Operational:

• Door-to-doc time
• Length of stay for discharged and admitted patients
• LWBS/LBT (left without being seen / left before treatment complete)
• Return visits within 72 hours
• Patient satisfaction metrics

Financial:

• Collections per visit and per RVU
• Provider productivity (RVUs/shift)
• Days in AR
• Denial rates and reasons
• Net profit margin and reserve levels

Use data to:

• Guide staffing adjustments.
• Support renegotiations with hospitals or payers.
• Justify expansion or adding new services (e.g., observation unit, teletriage).

Scaling Your Practice

Growth options include:

• Acquiring or bidding on additional hospital ED contracts.
• Opening new urgent care or hybrid ED/urgent care locations.
• Building a regional brand in unscheduled care.

With growth comes new challenges:

• Maintaining culture across multiple sites.
• Standardizing protocols and quality metrics.
• Ensuring fair partnership opportunities for newer members.
• Defending against acquisition offers that may or may not align with your long-term goals.

Exit Strategies and Long-Term Planning

From the beginning, plan for eventual transitions:

• Will the group ever sell to a larger entity?
• How will departing partners be compensated?
• What happens if a majority want to sell and a minority don’t?

These decisions intersect with the broader private practice vs employment debate. Some physicians value autonomy and distributable profits; others prefer the stability of hospital or corporate employment. Your practice can remain independent only if its owners share a long-term vision and commit to operating at a high level clinically and operationally.

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Frequently Asked Questions (FAQ)

1. Can I start a private emergency medicine practice straight out of residency?

Technically yes, but it’s rarely wise. Emergency medicine practice management is complex, and hospitals are often hesitant to award ED contracts to untested groups. A more realistic pathway is:

1. Match into a strong emergency medicine residency and focus on clinical excellence.
2. Spend a few years in community practice, learning operations, billing, and hospital politics.
3. Build relationships with potential partners and hospitals.
4. Then consider starting or taking over a private practice group.

You can, however, start laying groundwork—learning business basics, identifying mentors, and exploring markets—while still a resident or early attending.

2. What’s the financial risk compared with being an employed emergency physician?

As an employed EP, your income is more predictable; the employer absorbs most business risk. In private practice:

• Your income can be higher if collections and contracts are strong.
• Your income can be volatile if volumes, payer mix, or contracts change.
• You may invest your own capital (or take on debt) to get started, especially if opening facilities.

Starting private practice in EM is like owning any small-to-medium business: you trade security for potential upside and control. Before committing, ensure you have:

• Emergency savings.
• Realistic projections.
• A clear plan for worst-case scenarios (contract loss, volume drop).

3. How does the EM match and residency choice affect my chances of joining or starting private practice?

Your emergency medicine residency can shape your opportunities:

• Programs with strong community hospital exposure and independent group faculty can provide mentors and contacts in private practice.
• Academic-heavy programs may prepare you well clinically but give less exposure to business and operations.

Regardless of program type:

• Seek attendings who practice in independent groups and learn from them.
• Choose electives that emphasize community and operational experience.
• Attend national meetings where private practice groups recruit and network.

4. Is private practice still viable in emergency medicine given consolidation and large national groups?

Yes, but viability is market- and model-dependent:

• In some urban academic centers, independent ED contracts are nearly impossible to obtain.
• In many community and rural settings, hospitals still partner with local or regional physician-owned groups.
• There is also room for innovation in FSEDs, hybrid urgent care/EM centers, and tele-emergency medicine.

To remain viable, a private EM practice must:

• Offer clear value to hospitals (quality, stability, efficiency).
• Be sophisticated in billing, compliance, and operations.
• Maintain a cohesive ownership structure and culture that can withstand external pressures and acquisition offers.

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Starting a private practice in emergency medicine is ambitious, demanding, and risky—but for physicians who want ownership, autonomy, and the chance to shape patient care and ED culture at a systems level, it can be deeply rewarding. By understanding the unique contours of EM practice models, planning thoroughly, and building the right team and infrastructure, you can move from concept to a sustainable, physician-led emergency medicine practice.