Starting your dermatology practice, step by step.

01How to use this guide

Start the slow things first. Your employment contract, a new state license and insurance credentialing each set dates you can't move much. Plan everything else around them.

Read the timeline below first. It shows the whole job on one screen. Each numbered section then explains one area in plain words. Section 14 pulls every task into one printable checklist, and your check marks are saved in this browser.

Every number has a source. Fees, rates and prices link to the list at the bottom of the page, with the date each one was checked. Where we couldn't find a public source for a number, we left it out and told you what drives it instead.

A few words you'll see

The 6-month timeline

Already licensed in your state with a DEA registration and no non-compete? You can move faster on months 1 to 3. Credentialing is still the long pole.

02Leaving your current job Before month 1

Questions to bring your lawyer

• What is my earliest possible last day, and how do I give notice?
• Where exactly can't I practice, for how long, and can I buy out of it?
• What may my notice letter to patients say, and who sends it?
• Who pays for tail coverage in my situation?
• What happens to accrued bonuses, vacation and my case logs?
• Can I start entity, lease and credentialing work while still employed?

03Getting patients Months 3 to 6, then always

This is most new practice owners' biggest fear, and the work is not mysterious. It is a list of small tasks done in order and repeated. None of it involves buying reviews or paying for referrals, and most of it costs nothing but time.

1. Tell your current patients, within your contract

Use the notice letter you agreed on in section 02. When patients find you, make records transfer easy: put a one-page records release form on your website, and assign one staff member to follow up with the old office until the records arrive.

2. Build referral relationships

List the primary care, urgent care, pediatric, OB/GYN and podiatry offices within a reasonable drive. In month 5, visit them in person with a one-page sheet: what you treat, which insurance you take, how to send a referral (fax and e-referral), and how fast you will see an urgent referral, such as a changing pigmented lesion. Then keep that promise.

Send a consult note back after every referred visit. A fast, useful note is the best marketing a specialist has. Never give anything of value in exchange for referrals: the federal anti-kickback statute is a criminal law, and both sides of a deal can be liable HHS OIG.

3. Google Business Profile, done properly

• Claim and verify the profile at your practice address. It's free.
• Use your real name only. Google doesn't allow extra keywords or cities in the business name and can suspend profiles that add them Google.
• Pick one primary category, the most specific one that fits, and as few extra categories as you need Google.
• Know the practitioner rules. Google treats doctors as individual practitioners. A solo doctor practicing under a brand can use one profile named "Brand: Dr. Name"; a group keeps a practice profile plus one per doctor Google.
• Fill in everything: hours, phone, website, booking link, accessibility details. Add real photos of the building, entrance, parking, waiting room, an exam room and your team. Never patients.

4. Reviews, asked for ethically

• Ask every patient the same way, such as a text after each visit. Asking only happy patients ("review gating") breaks Google's policy Google.
• Never offer anything for a review. Google bans incentives outright. The FTC's rule, in force since October 2024, bans fake reviews, incentives tied to a positive or negative review, and suppressing bad reviews with threats FTC.
• Don't ask for specific content, such as naming a staff member. Google's policy forbids it.
• Reply without confirming the person is your patient. HHS has penalized practices that disclosed patient details in review replies: $50,000 and $23,000 in 2022, and $30,000 in 2023 HHS OCR. A safe reply: "Thank you for the feedback. We take every concern seriously. Please call our office manager at [number] so we can talk."

5. Payer directory listings, checked one by one

After each effective date, search that payer's online directory for yourself. Check your name, specialty, address, phone, "accepting new patients," and in-network status at the right location. Under the No Surprises Act, plans must verify directory information at least every 90 days and update it within 2 business days of a provider's update; you must send updates when a contract starts or ends, when your information changes, and when asked 42 U.S.C.. Keep the same details everywhere (NPPES, CAQH, your website, Google and each payer), down to the suite number. It's free, and a wrong listing quietly sends patients somewhere else.

6. Website must-haves

• Insurance you accept, by plan name, and whether you're taking new patients.
• Services: what you treat and what you don't.
• Location, parking, hours, phone, fax and an online booking link.
• About the doctor: training and board certification.
• New patient forms and a records release form.
• Self-pay prices and the Good Faith Estimate notice, which federal rules require on your website 45 CFR 149.610.
• Your Notice of Privacy Practices, posted prominently. HIPAA requires this when your site describes your services 45 CFR 164.520.
• Accessible design (WCAG 2.1 AA). A 2024 HHS rule requires that standard from recipients of federal financial assistance, now due May 11, 2027 for those with 15 or more employees and May 10, 2028 for smaller ones HHS. Ask your attorney whether it applies to you; building it in from day one is cheaper than fixing it later.
• Fast on a phone. Test every page on your own phone, on cellular data, before launch.

7. Signage and local visibility

• Exterior sign and building directory: get landlord approval written into the lease, and your city's sign permit, before you order.
• Hospital and society listings: if you hold privileges, tell the medical staff office and the hospital's referral line. Join your county medical society.
• One name, one address, one phone number everywhere patients might look.

04Entity and licensing Month 1

These are the legal basics. Most are quick and cheap. A new state license is the exception, so start it first if you need one.

Also check

• Local business license, zoning for medical use, and sign permits.
• Other insurance: general liability, property, cyber, and workers' compensation, which most states require once you have employees.
• State extras: some states require registering lasers, registering as a medical waste generator, or following office-based surgery rules if you use sedation beyond local anesthesia.

05Credentialing and payer enrollment Start month 1

How long it takes. Payers publish their own credentialing times: 45 to 60 days at Cigna, and about 45 days at Anthem once your CAQH profile is complete Cigna, Anthem. Those numbers don't include contracting, missing documents or closed networks. Medicare's contractors aim to finish most online applications without a site visit in 15 days and all within 50, and applications that need a site visit or fingerprinting within 85 days; the clock stops while they wait on you FCSO. Put together, plan on 2 to 6 months from your first application to your last effective date.

Do it in this order

1. Gather your documents in one folder. State license, DEA, board certification, diplomas, a CV with month-and-year dates (explain any gap of a few months or more), malpractice certificate and claims history, both NPIs, the practice EIN and a W-9.
2. Build your CAQH ProView profile. CAQH now operates as DataSpring. The profile is free for clinicians, most commercial payers pull your information from it, and you must re-attest every 120 days or payers may treat your profile as lapsed DataSpring.
3. Enroll in Medicare through PECOS. Enroll yourself and the practice, and reassign your benefits to the practice. Physicians and physician groups pay no enrollment application fee (institutional providers pay $750 in 2026) CMS. Your effective date is the later of the date Medicare receives an application it approves and the date you start seeing patients at the new location; you may bill for up to 30 days before it if circumstances kept you from enrolling earlier 42 CFR 424.520, 424.521.
4. Choose your Medicare status. Participating (you accept Medicare's rate as payment in full), non-participating, or opting out (patients pay you directly and nobody bills Medicare). Opting out lasts 2 years and renews automatically unless you cancel at least 30 days before the period ends 42 CFR 405.445. You revalidate your Medicare enrollment every 5 years CMS.
5. Enroll in Medicaid, if you'll accept it. Each state runs its own enrollment, and Medicaid managed care plans usually credential you separately.
6. Apply to each commercial payer you want, including Medicare Advantage plans, which credential separately from Medicare. First ask whether the network is open for dermatology in your area. Some are closed or slow.
7. Read the contract before you sign. Credentialing approves you. The contract sets what you're paid. Ask for the rates for your 10 most common codes.
8. Get each effective date in writing before you book that payer's patients.

Track everything

Applications stall quietly. Keep one tracker with these columns: payer, date sent, reference number, contact, next follow-up date, status, effective date, ERA and EFT status. Call every two weeks until each one is done. The payer tracker download is set up this way.

One more Medicare note: the quality program MIPS skips clinicians in their first year of Medicare enrollment, but only if you have never billed Medicare before, even through a group 42 CFR 414.1305. If you're leaving a Medicare-billing job, plan for MIPS from year one.

06Money and billing setup Months 2 to 6

Decide who does billing

You have three common options: a billing service, an in-house biller, or you and your staff using billing software. Billing services charge a percentage of what you collect. Published dermatology figures are old: 5% to 7% of net collections (2006) and 5% to 9% (2012) Dermatology Times. A 2026 consultant guide quotes 5% to 8% DoctorsManagement. Compare what each quote includes: patient statements, denial appeals and prior authorizations are often extra.

The break-even math. A medical records specialist (the federal category for billers and coders) earns $37,000 to $81,150 a year nationally, with a median of $51,140 BLS. Add the 7.65% employer tax and a median biller costs about $55,000 a year before benefits. At a 6% fee, a billing service costs the same once you collect about $918,000 a year. Below that, a service is usually cheaper; above it, in-house may be, if you can cover the biller's vacations and train a backup. Whatever you choose, one named person must own denials, follow-up and patient balances every week.

Clearinghouse, ERA and EFT

A clearinghouse sends your claims to payers and brings back payment files. Many EMRs include one or partner with one. For each payer you'll enroll for three things: electronic claims, ERA (electronic remittance advice, the file that explains each payment) and EFT (electronic funds transfer, direct deposit). Start ERA and EFT enrollment in month 5 at the latest; each payer runs its own process.

Your fee schedule

Your fee schedule is your list price for each code. It isn't what you get paid. Payers usually pay the lower of your charge or their contracted rate, so a fee below a payer's rate leaves money on the table. That is why many practices set every fee as one multiple of Medicare: it keeps fees consistent across codes, it's easy to update when Medicare publishes new rates each year, and if the multiple is high enough, every fee stays above every contract. Use one fee schedule for all payers.

If you choose to be non-participating with Medicare, you may not charge Medicare patients more than the "limiting charge," which is 109.25% of the participating amount. For 99213 nationally, that's $104.00 in 2026 CMS.

Self-pay pricing

Set clear cash prices for cosmetic services and for patients without insurance. Keep the list short, written down and applied the same way to everyone. Before offering discounts to insured patients, check your payer contracts and state rules.

Good Faith Estimates

Under the federal No Surprises Act, you must give uninsured and self-pay patients a written Good Faith Estimate of expected charges. That includes cosmetic patients paying cash 45 CFR 149.610.

• Scheduled at least 3 business days ahead: give the estimate within 1 business day of scheduling.
• Scheduled at least 10 business days ahead: within 3 business days of scheduling.
• When a patient asks: within 3 business days of the request.
• Post a notice that estimates are available on your website, in your office and where patients schedule, and tell patients when they schedule.
• If the final bill is at least $400 above the estimate, the patient can dispute it through a federal process within 120 days of the first bill 45 CFR 149.620.

ABNs for Medicare patients

An Advance Beneficiary Notice tells a Medicare patient, before the service, that Medicare may not pay. You need one before a normally covered service you expect Medicare to deny as not medically necessary; without it, the practice can't bill the patient. For services Medicare never covers, such as cosmetic procedures, an ABN is optional. Don't hand out ABNs routinely, and keep copies for 5 years CMS.

Getting paid at the front desk

• Check insurance eligibility the day before every visit, not at check-in.
• Collect copays and known balances at check-in. Keep a card on file with written consent.
• Write a financial policy covering copays, no-shows, payment plans and cosmetic deposits. Have patients sign it.

Test before day one

Send test claims through your clearinghouse to every major payer before you see real patients. Fix rejections now, while there's no money at stake.

07CLIA, pathology and iPLEDGE Months 3 to 5

CLIA is the federal program that covers any lab test done on a patient sample in your office. If you do any testing in the office, even a urine pregnancy test, you need a CLIA certificate for that location. Sending biopsies to an outside lab doesn't need one; reading anything yourself usually does.

Fees from the CMS CLIA certificate fee schedule (updated 2024), every two years. For a Certificate of Compliance at 2,000 or fewer tests a year: $223 plus an average state survey fee of $446; for a Certificate of Accreditation: $223 plus $22, plus your accrediting organization's own fees CMS.

How to apply

• Fill out form CMS-116 and send it to your state's CLIA agency. You need the practice address first.
• CLIA is paperless now. CMS emails certificates and fee notices, and fees are paid online through pay.gov, so keep a working email on file CMS.
• New York and Washington run their own lab programs in place of federal CLIA certification. Some other states add their own rules on top.

Pathology economics: send it out or read it yourself

Sending out is the default for most new practices. You bill the biopsy; the lab bills the slide work to the patient's insurance. For a sense of scale, Medicare's 2026 national amount for the standard tissue exam code 88305 is $70.14, split into $35.07 for preparing the slide and $35.07 for the pathologist's read CMS. You need no lab staff, no equipment and no high-complexity certificate.

Reading your own slides only makes sense if you are trained and credentialed in dermatopathology. You then need either an in-house histology lab with its own high-complexity CLIA certificate or an arrangement with a lab that prepares the slides. Either way you run into the federal self-referral (Stark) law, whose in-office ancillary services exception has strict rules on who does the work, in which building, and who bills CMS, 42 CFR 411.355. Talk to a healthcare attorney before you build it.

What labs may and may not give you. Items used only to collect, transport, process or store specimens, order tests or send results (jars, requisitions, courier pickup, a results interface) are fine. Free computers or fax machines you use for other work, free staff, or waste pickup unrelated to specimens are red flags under the anti-kickback statute HHS OIG.

Choosing a pathology lab

• Are your readers board-certified dermatopathologists? Can I call the pathologist directly?
• What is your usual turnaround for a routine skin biopsy, and for a rush?
• How do results reach me: an interface into my EMR, a portal or fax?
• What are courier pickup times and the daily cut-off? What happens on Fridays and holidays?
• Which insurance plans are you in-network with? An out-of-network lab can surprise your patients with bills.
• How do you price for uninsured patients, and will you give that price in writing for Good Faith Estimates?
• Which special stains, immunostains and send-out tests do you offer?

What turnaround to promise patients

Ask your lab for its usual turnaround on routine skin biopsies. Then promise patients a window a few days longer, and tell them you will contact them either way, even when the result is benign. A longer promise you keep builds more trust than a short one you miss.

Courier and requisition reality

• The requisition carries the bill. Wrong or old insurance on the requisition becomes a bill to your patient. Check it at check-out.
• Know the cut-off. A jar that misses today's pickup waits until tomorrow, or until Monday.
• Count every jar against the log before the courier leaves, and keep a copy of the manifest.

Specimen flow: from biopsy to patient

1. Label in the room. Two patient identifiers, body site and specimen letter, on the jar, in front of the patient.
2. Write a useful requisition. Clinical history, your differential, exact site and procedure type. A better history gets a better read.
3. Log it the same day. Every specimen goes into a tracking log in your EMR or on a sheet.
4. Hand off to the courier. Count the jars against the log and keep a copy.
5. Review the result. You read and sign every report.
6. Tell the patient. Document how and when they were told, and the plan.
7. Close the loop weekly. Any specimen without a result past your lab's normal turnaround gets flagged and chased.

A biopsy result that never reaches the patient is a real safety and malpractice risk. The log is what closes the loop: every jar in, every result back, every patient told.

iPLEDGE: what isotretinoin really involves

iPLEDGE is the FDA-required safety program for every isotretinoin product. You, your patient and the pharmacy all work in the same system, and it creates steady monthly work for your front desk FDA.

• Register and activate. Only enrolled, activated prescribers may prescribe, and you must re-activate every year. Staff "designees" can enter data, but only you can activate a patient's enrollment iPLEDGE.
• Two patient categories: patients who can get pregnant, and patients who cannot.
• Pregnancy testing for patients who can get pregnant: a screening test before enrollment and a confirmation test before the first prescription, both in a medical setting such as your office or a lab; then a test every month before each prescription, one after the last dose and one a month later. Since 2023 the FDA has allowed tests outside certified labs, and home tests during and after treatment if you permit them, but you must interpret and record every result and guard against falsified home results. Running urine pregnancy tests in your office needs at least a CLIA Certificate of Waiver.
• The 7-day window: for patients who can get pregnant, the prescription must be picked up within 7 days, counting from the day the pregnancy test sample was taken.
• Every month, you confirm counseling, enter the test result and the patient's two forms of contraception, and the patient answers comprehension questions before the pharmacy can dispense.

The front-desk work it creates: book every isotretinoin visit on a fixed monthly rhythm; time the pregnancy test so the 7-day window lines up with pharmacy pickup; have a trained designee do the system entries; field pharmacy calls; handle prior authorizations; and keep one list showing where each patient is in this month's cycle.

08Space, procedure room and Mohs Months 1 to 6

Pick the space for the work you'll do, and leave room for the work you may add. Check that zoning allows medical use, that plumbing can reach every room that needs a sink, and that the landlord's construction timeline fits yours.

Room list

• Waiting area and check-in desk, with enough privacy for insurance and money conversations.
• Exam rooms: enough that the next room is ready when you walk out of the last one, so you never wait on a turnover.
• Procedure room: larger than an exam room, a power chair you can reach from both sides, a strong overhead light and a sink.
• Clean utility and sterilization area, kept separate from a dirty area for used instruments.
• Lab corner: microscope, specimen prep and secure specimen storage.
• Medication storage: locked, with a separate medication fridge and a temperature log.
• Liquid nitrogen spot: well ventilated, never a small closed closet.
• Photo spot: consistent light and a plain backdrop for clinical photos.
• Staff area, storage, your office and an accessible restroom. Check ADA rules for the whole space.

Equipment, with real prices

Prices below are listed prices from US dealers, checked October 27, 2026 dealer listings. Big items are often sold by quote, so treat these as ceilings for new and as examples for refurbished.

We could not verify current public prices for microscopes, procedure lights, instruments, furniture or computers, so they're left out here. Put your own quotes into the budget worksheet.

Supplies to stock

• Punch tools in common sizes, curettes, blades
• Absorbable and non-absorbable sutures
• Needle drivers, forceps, scissors, skin hooks
• Lidocaine with and without epinephrine
• Syringes and needles
• Aluminum chloride and silver nitrate
• Gauze, dressings, petrolatum, tape
• Formalin specimen jars, requisitions, bags
• Sterile and exam gloves, drapes, masks, eye protection
• Skin prep and surgical marking pens
• Injectables you use often, like intralesional triamcinolone
• Gowns, table paper, disinfecting wipes

Safety and compliance

• OSHA bloodborne pathogens plan and staff training, plus hazard communication with safety data sheets for formalin and other chemicals.
• Contracts for sharps and biohazard waste, and for shredding.
• Sterilization records: an autoclave log and regular spore testing, if you sterilize in-house.
• Liquid nitrogen safety: ventilation, handling training and protective gear.
• Emergency kit: epinephrine, blood pressure cuff, pulse oximeter and an AED, checked monthly.

Mohs: offer it, refer it, or phase it in

Mohs surgery means running a high-complexity laboratory inside your office. CMS classifies the microscopic exam and interpretation of Mohs frozen sections as high-complexity histopathology CMS. Before you decide, know what that requires.

• A CLIA Certificate of Compliance or Accreditation. You start on a Certificate of Registration ($123), valid while you apply, then move to compliance (state inspection) or accreditation (through an approved accrediting organization) CMS.
• A qualified lab director. Since December 28, 2024, a non-pathologist director needs 2 years of experience directing or supervising high-complexity testing plus 20 hours of continuing education, unless grandfathered 42 CFR 493.1443. A June 2025 CMS memo says CMS will let dermatologists certified by the American Board of Dermatology, who qualify as dermatopathology technical supervisors, direct dermatopathology labs CMS QSO-25-21. A proposed rule published October 8, 2026 would write dermatology board certification into the regulation; it is not final CMS-3478-P.
• Accuracy checks twice a year. There is no approved proficiency testing program for Mohs, so the lab must verify its accuracy at least twice a year another way 42 CFR 493.1236.
• A histotechnician. BLS doesn't publish a separate wage; clinical laboratory technologists and technicians earn $38,910 to $100,990 a year nationally (10th to 90th percentile, May 2025) BLS.
• Equipment: a cryostat (a refurbished Leica CM1860 lists for $20,250 to $24,500 IMEB; new units cost more, so get quotes), plus staining setup, slides, reagents and a microscope.
• Space: a lab room with a sink, ventilation for chemicals and power for the cryostat, plus somewhere comfortable for patients to wait between stages.

For scale, Medicare's 2026 national in-office payment is $667.02 for the first Mohs stage on the head, neck, hands, feet or genitalia (17311) and $402.81 for each additional stage (17312) CMS.

09Cosmetics and lasers After opening

Why a laser is usually not a month-one purchase

Even used, a laser can cost more than every item in the equipment table above combined, and month one is when cash is tightest and demand is unknown. For example, a used Candela GentleMax Pro was listed at $60,000 on a major equipment marketplace in October 2026, and a used-laser broker says used devices save 50% to 80% compared with new DOTmed, The Laser Agent. On top of the price come service contracts, consumables, staff training, and your state's rules on who may operate a laser and under what supervision. Ask your malpractice carrier how cosmetic procedures change your premium. Open first, learn what your patients ask for, then buy.

Buy, lease, or buy used

Cosmetic consults and pricing

Decide whether you charge for a cosmetic consult and whether the fee is credited toward treatment booked the same day, then post the policy. Cosmetic patients pay cash, so the Good Faith Estimate rules in section 06 apply. Medicare doesn't cover cosmetic procedures, so an ABN is optional for them.

Retail skincare

The AMA's ethics opinion on selling health products in the office (Opinion 9.6.4) sets the standard: sell only products with scientific support, tell patients about your financial interest and that they can buy elsewhere, avoid exclusive distributorships, and limit sales to products that meet patients' immediate needs, ideally at or near cost AMA. You may also need to register to collect state sales tax, and inventory ties up cash.

Standardized photography

• Same setup every time: same camera, distance, lighting and plain background, with standard poses (front, 45 degrees, profile).
• Separate consents for clinical photos and for any marketing use. Never post a patient photo without written authorization.
• Store photos in your EMR, not on personal phones.

10Staffing and daily workflow Months 4 to 6

Start lean and hire as the schedule fills. In a small office one person often covers two roles at first. What a medical assistant may do differs by state, so check before assigning tasks like injections.

What to automate

• Appointment reminders and confirmations by text or email
• Online intake forms and consents, filled out before the visit
• Insurance eligibility checks the day before
• Card on file and automatic statements
• Recall reminders, such as yearly skin checks and monthly isotretinoin visits
• Incoming faxes routed into the EMR, not printed
• Pathology tracking with overdue flags

Front desk design

• Privacy at check-in, so insurance and money talk isn't overheard.
• One main number with a short menu. Return voicemails the same day.
• Short scripts for new patients, cosmetic pricing, refills and results calls. Results questions go to the clinical team.
• Posted policies for no-shows, late arrivals and cosmetic deposits, also included in intake.
• A day-before check: eligibility verified, prior authorizations in place, forms complete, isotretinoin patients' tests timed.

A day in the clinic

1. Morning huddle, 5 minutes: the schedule, add-ons, procedures, and any results to call back.
2. Check-in: confirm insurance, collect copay, intake already done.
3. Rooming: MA takes history and photos and sets up any procedure.
4. Visit: you examine, decide and document. Specimens are labeled in the room.
5. Check-out: follow-up booked, Good Faith Estimate given if a cash service is scheduled.
6. End of day: notes signed, claims reviewed and sent, specimen log matches the jars.

11Technology and choosing an EMR Months 2 to 5

Your EMR touches every visit, every claim and every patient message, and it's the hardest system to leave. Judge every vendor by the same questions. Get the answers in writing, ideally in the contract.

Dermatology must-haves

• Photos tied to body sites, so you can compare the same lesion across visits.
• Closed-loop pathology and lab tracking: every specimen logged, overdue results flagged, every result signed, every patient notification documented.
• Procedure documentation that captures what billing needs: site, size, margins, technique, repair, lesion counts and consent.
• Dictation or voice input that understands dermatology terms, so you aren't typing in the room.
• E-prescribing, including controlled substances. DEA rules for electronic controlled-substance prescriptions require identity proofing and two-factor sign-off 21 CFR 1311.
• Billing that traces every code to what was documented. You should be able to click any code on a claim and see the words in the note that support it.

The exit questions

A practice that can't leave its EMR is trapped. Ask before you sign:

• Who owns the data? The contract should say you do.
• How does a full export work? All notes, structured data, photos, scanned documents, prescriptions, claims and payment history, in formats another system can import, not just PDFs.
• What does export cost, and how long does it take? Get both in the contract.
• Do you keep read-only access after you leave, and for how long?

The security questions

• Encryption of data in storage and in transit.
• Backups you can actually restore. Ask when they last restored a practice from backup, and how long it took.
• Audit logs showing who viewed or changed each record, which you can see yourself.
• A signed BAA before any patient data goes in.
• After a breach: how fast they notify you (HIPAA allows a vendor no more than 60 days after discovery, and expects sooner) 45 CFR 164.410, who pays for patient notification, and what incidents they've had.

The money questions

• Price per provider per month, and what staff seats cost.
• Setup, training and data migration fees.
• Add-ons: e-prescribing, controlled-substance prescribing, patient portal, texting, fax, clearinghouse, lab interfaces.
• Whether billing is priced as a percentage of collections.
• Contract length, renewal price increases, auto-renewal and cancellation terms.

The demo test

Ask for one real visit on a test patient, end to end: a new patient with a rash and a changing mole, a shave biopsy, and destruction of three actinic keratoses. Then watch the path result arrive, the patient get notified, and the claim go out. Time it and count the clicks. A vendor that won't run this demo is telling you something.

Red flags

• Long contracts with no written export terms.
• Per-seat charges for every staff login.
• Codes the system adds on its own, without words in the note behind them.
• Demos that won't show a real visit end to end.
• No BAA until after you sign, or no answer about breach notification.
• Export "available" only as PDFs.

The rest of the stack

• Phone: a business phone system with reminders and texting. If it stores voicemails or texts with patient information, get a BAA. Make sure you own your number.
• Fax: you'll still need one. Use a secure e-fax service that lands in your EMR or inbox.
• Online booking: with rules, such as longer slots for new patients and a call first for procedures.
• Payments: card reader, card on file and text-to-pay.
• Security basics: a separate login for each person, two-factor login everywhere, encrypted laptops, automatic screen locks, backups, and a written HIPAA risk assessment.
• Business email on your own domain. Don't send patient information by regular email.

12Costs and an opening budget

Two lines decide what opening costs you: the build-out and the rent. Everything else is smaller and easier to predict. The worked budget below shows the math with sourced inputs, so you can swap in your own quotes.

Fees and prices at a glance

Every figure in this table links to its source in Sources. Government fees were checked October 27, 2026 and can change.

13Common mistakes that delay an opening

1. Signing a lease or announcing before your lawyer reads your contract. The non-compete and notice period may move your date or your location.
2. Taking patient lists or copying charts on the way out. It can breach your contract and HIPAA. Use an agreed notice letter instead.
3. Forgetting tail coverage. Find out who pays before you resign, not after.
4. Starting credentialing late. Start 6 months out and follow up every two weeks.
5. Letting CAQH lapse or leaving gaps. Re-attest every 120 days, explain gaps in your CV, and replace expired documents before payers ask.
6. Signing a lease that doesn't fit. Check zoning for medical use, room for a procedure room (and a future Mohs lab), plumbing for sinks and the landlord's timeline.
7. Underestimating the build-out. Permits, inspections, contractor delays and equipment lead times add up. Build in a buffer.
8. Booking patients before a payer's effective date. Get the date in writing first.
9. Never checking payer directories. A wrong address or "not accepting patients" quietly sends patients elsewhere.
10. Stuffing keywords into your Google business name. It breaks Google's rules and risks suspension right when you need the listing most.
11. Asking only happy patients for reviews, or offering anything for them. Ask everyone the same way, and never pay.
12. Forgetting CLIA for small tests. A KOH prep or a urine pregnancy test still needs a certificate.
13. Skipping ERA and EFT enrollment. Payments arrive as paper checks, or stall.
14. Opening without a biopsy log. Set it up before your first specimen.
15. Buying a laser in month one. Learn what your patients want first.
16. Running short on cash. Insurance money starts slowly. Have reserves or a line of credit.
17. No Good Faith Estimate process for cash and cosmetic patients.
18. Not testing claims before the first real ones go out.

fluencederm.com/guide · Opening checklist · General information, not legal, tax or financial advice.

14Final opening checklist

Check items off as you go. Your check marks are saved in this browser only, on this device.

Free downloads

Three working files to run your opening, free:

• The opening checklist (PDF). Everything in section 14 on clean printable pages, grouped by area.
• The opening budget worksheet (Excel). Exhibit B with every line editable: enter your quotes and it adds up your low and high totals.
• The payer tracker (Excel). One row per payer, with the columns from section 05: dates, reference numbers, follow-ups, effective dates, ERA and EFT.