When you're opening a practice, everyone has an opinion. Your bank wants to give you a loan. Your EHR vendor wants a multi-year contract. Your landlord wants you in the largest space they have available. A well-meaning colleague tells you what worked for them five years ago, in a different state, with a different payer mix.

Most of this advice is not malicious. It is, however, shaped by the interests of the person giving it.

What follows is drawn from what we've observed across hundreds of NP practice launches — the decisions that consistently separate practices that build something durable from those that spend their first two years putting out fires.

The EHR Decision Is More Consequential Than It Looks

Most NPs choose an EHR the way most people choose a contractor: a trusted colleague recommended it, or the price was right. Those are reasonable starting points. They are not sufficient criteria for a decision that will shape how your practice bills, documents, and grows for years.

There are four things EHR vendors are unlikely to tell you upfront.

First: not all EHRs are government-certified, and that matters more than it sounds. The federal government maintains the Certified Health IT Product List (CHPL) — the authoritative list of EHR systems that have been tested and approved to meet CMS requirements. If your EHR is not on that list, you cannot participate in federal programs like ACO REACH or the Medicare Promoting Interoperability Program. Many NPs discover this only after they've built their entire practice on an uncertified system and are trying to join a value-based care arrangement. The fix is disruptive and expensive.

Second: the billing and practice management system built into your EHR may not be adequate. Many platforms bundle a billing module that looks functional in a demo and reveals its limitations only when you're actually submitting claims, tracking denials, and reconciling payments. By then you've already built your workflows around it. A billing system that handles 200 patients a month adequately may fall apart at 800. Ask specifically how the system handles denial management, remittance reconciliation, and secondary claim submission before you sign.

Third: the pricing model changes as you grow. Several EHRs that are inexpensive at launch charge incrementally for features you will eventually need — telehealth, patient messaging, additional providers, reporting modules. The monthly cost that made sense at launch can double or triple by the time you're established. Get the full pricing schedule for the practice size you intend to build, not just the entry tier.

Fourth: configuration determines performance more than brand. Across the practices we work with, we see significant variation in billing outcomes among practices using the same EHR — because documentation templates, coding prompts, and workflow structure are set up differently in each one. A system with poorly configured templates will consistently underrepresent visit complexity, leading to undercoding that compounds quietly over thousands of visits.

The right questions to ask before choosing an EHR are: which patients do you intend to serve, and how large do you plan to grow? A solo provider focused on commercially insured patients has different requirements than a two-provider practice building toward ACO participation with a Medicare-heavy panel. Those answers should drive the comparison, not the vendor's demo.

Duet provides a free EHR analysis for NPs in the planning stage. Talk to an advisor →

Credentialing Timelines Will Surprise You

Start earlier than you think you need to. Then start earlier than that.

Medicare enrollment through PECOS typically takes 60 to 90 days. Most commercial carriers take 90 to 120 days. Some state Medicaid programs take longer. These are not delays you can negotiate or expedite through persistence. They are the actual administrative timelines of large insurance organizations, and they run whether or not you are ready to see patients.

The financial consequence of a credentialing delay is straightforward and significant. A primary care practice seeing patients but not yet credentialed with major payers is either turning away insured patients, seeing them at a loss, or accumulating a backlog of unbilled claims that will take months to process once enrollment is approved. None of these are recoverable situations. They are avoidable ones.

One detail that catches many new practice owners: CAQH — the universal credentialing database that most commercial payers draw from — requires attestation every 120 days. A lapsed CAQH profile can restart the credentialing clock entirely. Keep it current from the moment you create it.

Space and Debt Are Risks, Not Investments

The practices that struggle most in their first year almost uniformly share one characteristic: they opened too large, with fixed costs that created financial pressure before their panel was built.

There is a version of practice launch that looks like success — a dedicated space, a full front desk, a medical assistant, a waiting room with tasteful furniture — and functions like a trap. Fixed overhead that exceeds revenue in months one through six forces decisions that are hard to walk back: seeing more patients than is sustainable, taking on payer contracts at unfavorable rates just to fill the schedule, borrowing against future revenue that may not materialize on the timeline assumed.

Sublet a room. Co-locate with another provider. Start in a space that is genuinely too small for where you want to be in three years. You can grow into space. Shrinking from debt is considerably harder.

The same logic applies to hiring. The impulse to staff up early feels like growth. In most cases it is cost, arriving before the revenue that would justify it. Hire when the patient load makes it operationally necessary, not when it would feel more like a real practice to have people around.

Your First Ninety Days Are a Marketing Asset

Most new practices wait until everything is ready — all contracts live, full schedule open, website polished — before seeing patients. This is understandable and usually a mistake.

The period before your commercial credentialing is complete is not dead time. Cash-pay visits at transparent pricing, low-cost initial appointments, and in some cases pro bono care for patients who genuinely need it serve a function beyond the immediate revenue: they build your panel with people who have experienced your care before you needed them to.

Every early patient is a potential long-term patient, a potential review, and a potential referral. The practices that grow most reliably in their first year are usually not the ones with the best marketing. They are the ones who were generous with their time early and whose patients remembered it.

The Business You're Building Is Not the Practice You're Imagining

This is the hardest thing to say clearly without sounding discouraging, so it is worth being direct: opening an NP practice is an act of clinical courage and an act of business formation, and the second requires as much preparation as the first.

The clinical preparation is extensive. The business preparation — financial modeling, payer strategy, billing infrastructure, legal entity structure, credentialing sequencing — is largely self-taught, because it is not part of NP education and there is no standardized pathway for it. As Lindsey Maloney, founder of Nutmeg Primary Care in Connecticut, put it: "We don't learn this stuff in school. Billing is never taught and it's such a big part of our jobs. When it's your company, who's fixing the billing? No one."

The answer to that question — who is fixing the billing, managing the contracts, optimizing the coding, and watching the remittances for silent downcodes — is the difference between a practice that builds equity over time and one that generates a lot of activity while quietly losing ground.

Getting that infrastructure right before you open, rather than retrofitting it after the fact, is the single highest-leverage thing a new NP practice owner can do.

Learn how Duet supports NP-owned practices from launch through scale →