#209 She Left the Colonoscopy Treadmill. Here Is How She Gets Paid Now

 Dr. Emily Ward knew in March 2020 that she was done. She left her gastroenterology partnership in 2023. The reason for the gap was not fear. The practice worked, the money was good, and staying was the rational choice every morning until it was not. She joins Heather to walk through what she built after that, and the part nobody puts in the announcement post: how you actually get paid once you step outside the systems that normally do the paying. 

THE BACKGROUND 

Board certified in internal medicine and pediatrics before gastroenterology, with early microbiome research behind her. Ten years in private practice, most of it colonoscopy after colonoscopy with very little conversation attached. 

THE FIRST PIVOT 

GutsyRx, an online gut and rectal health marketplace for women, built for the patient she was in 2020: postpartum, perimenopausal, and unable to find anyone to talk to about it. 

THE SECOND PIVOT 

The community kept asking when she was coming back to see people in person. She opened a cash-pay concierge clinic in 2025. No payer contracts, opted out of Medicare. 

THE THREE PAYMENT PATHWAYS 

Pathway 1: her own cash-pay endoscopy center. She got as far as a pro forma with a consultant who had launched endoscopists before. His read was that she would need payer contracts for the numbers to work, which defeated the point. 

Pathway 2: employment at a facility, patients paying her consultation fee and running the procedure through insurance. Compliance gets murky against a Medicare opt-out, and she loses the scheduling control that makes high-touch care possible. 

Pathway 3: the hybrid, and the one she runs. Patients pay her professional fee directly. Facility, anesthesia, and pathology go through insurance or cash, patient's choice. Every patient so far has chosen insurance for that portion. 

WHAT SHE WOULD DO DIFFERENTLY 

She would not have built the WordPress and custom e-commerce platform to the depth she did. That capital would have moved further inside the in-person practice. 

THREE ACTIONS THIS WEEK 

• Write down which parts of your week you would keep if the revenue stayed flat. That is the list worth building around. 

• If you run any cash-pay service alongside insurance, confirm the two sides reconcile independently and nothing is being written off into the gap. 

• Before your next platform investment, ask what the same build would cost eighteen months from now. The answer has changed. 

OUR GUEST 

Dr. Emily Ward, MD, GutsyRx 

gutsyrx.com  |  Instagram @gutsyrx_guthealth  |  LinkedIn: [insert profile URL] 

FREE RESOURCE 

Practice Financial Health Dashboard for Physicians 

eligibility.natrevmd.com/free-practice-financial-health-dashboard-for-physicians-natrevmd 

RECOVER DIAGNOSTIC 

eligibility.natrevmd.com/recover-quiz-lp 

MORE FROM US 

Payment Posting Audit Checklist: eligibility.natrevmd.com/payment-posting-checklist 

Everything else: natrevmd.com 

MENTIONED 

The 6 Types of Working Genius by Patrick Lencioni

Transcript

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SPEAKER_00 0:04

20 years ago it was the circle towards employment, and now we're seeing that circle toward founders and creative and interesting products or ideas or things that really solve the patient's true issues. Welcome to Nat RevMD, a podcast where we share tips on optimizing medical billing and improving practice efficiency so you can have the business of your dreams. I'm your host, Dr. Heather Signorelli, founder of Nat RevMD. Let's get started. Give us your background. How did you go from GI independent practice to, you know, what you're building and doing today? And just maybe take us back to the beginning a little.

SPEAKER_01 0:43

So my background is in internal medicine and pediatrics. I was initially board certified in both and practiced for a while in that realm. I was always super interested in working on lifestyle and nutrition and seeing the whole person, hence internal medicine, pediatrics, then eventually matriculated to gastroneurology, which there's a lot of nutrition and metabolism derived through our gut health. Because I really wanted to see patients and not stay in academics and do research, I went into private practice. Though I did have a background of working on the microbiome pretty early. It wasn't a hot popular word. It wasn't social media at that time, but I did a lot of microbiome research and patients that were trying to lose weight and patients going on acid blockers and just understanding the diversity in composition, how it's affecting us at a more higher clinical level. So I had kind of that background of whole person, lifestyle, metabolism, nutrition. And you know, after like 10 years and private practice and you know, being a lady in medicine and I, you know, was an older mom. I had fertility issues, right? Just like all of us, like lady physicians. So finally I had babies, my body's breaking down. I'm slugging in out doing colonoscopy after colonoscopy. And then, you know, well, we, you know, COVID pandemic comes, March 2020, right? And my all my male partners, I didn't have a lady partner, all my male partners are like, Emily, get us up on telemedicine. So I was sitting there breastfeeding, terribly miserable, having like my own health issues, wanting to talk with a doctor, a female doctor. And okay, maybe I did go online and like look for products too. But I was like, you know, like, why isn't there like this gut and rectal health for for women, women like me, women who like have babies older, perimeticausal, like, where is this? So that was like my first pivot in my brain was, you know, me trying to survive the roller coaster of the 2020 COVID pandemic. And we had to shut down our facilities, and I got us all up a telemed telemedicine, etc. But it took me several years. Like that was 2020, and I didn't end up leaving the practice till 2023. A lot of logistics with non-complete causes and being a shareholder, you know, not leaving the area, but still being in the area. So there was a lot of logistics to starting to open a gut and rectal health marketplace for women. So that was my initial, initial pivot. And once I left the practice in 2023, um, I I took a lot of my investment money and and put it into the website. So that was my initial thing. I didn't know if I was gonna go back to endoscopy and colonoscopy. I was like, you know, I just wanna focus on talking to women, making women feel good, offering complimentary, clean products. Initially, I started with rectal ointments and suppositories, sort of remade them with a partner compounding pharmacy, which is a whole other conversation. I don't even know if we talked about like trying to find partners to like jump on your idea, right? You're you come up with these ideas on the whiteboard and you're I see ideas. I want to check them off. Yeah, yeah, let's do it, let's do it, let's get it done. And so, you know, there was a lot of conversations and networking and trying to get a compounding pharmacy to, you know, see my vision. And eventually when I did get up and running with the marketplace, the feedback was when you do an endoscopy. I want to send somebody to you, you know, still being here in Colorado. I opened up Colorado and Ohio because I'm from Ohio, born and raised.

SPEAKER_00 4:30

But Gutsy RX, but Gutsy RX, like from a marketplace perspective, you weren't doing anything in person. It was all online, right?

SPEAKER_01 4:37

It was, yeah, all online. It is online.

SPEAKER_00 4:39

It is online.

SPEAKER_01 4:40

It is online. Yeah. So initially it was kind of like virtual consult to kind of help you pick a product because I I was getting feedback that unlike our hair and skin, women want to talk with somebody about their other products. So like some complimentary things that a traditional GI doctor wouldn't provide, something like Lodose Naltrexel, or the rectal ointments and creams and some pastor. So, you know, I had that up for for quite a while. And then eventually, because of the community reach out of hey, when you come on, when are you like really coming back to see people in person, which you can do so much more in person? I I decided to open the concierge clinic in 2025. I don't know. Yeah. Yeah.

SPEAKER_00 5:26

And that's quite a year in. Yeah. And then so that is traditional GI practice, seeing patients going to surgery centers, but charging them all cash.

SPEAKER_01 5:36

Yeah. So it's a little bit, it's a little bit of a fine line. So it is a concierge clinic, an all-cash pay clinic, direct specialty clinic. And patients pay me in cash for my consultative services. Trying to get, so this is like one of the questions you you asked, like, what's like one of the hardest things that you had to figure out? And one of the hardest things I had to figure out was how to offer endoscopy services this way, right? Yeah.

SPEAKER_00 6:03

So do I know exactly and like if they're in network with the surgery center and out of network with you, and how that all falls together, correct?

SPEAKER_01 6:11

Right. So I don't contract at all with insurance. I Medicare opted out for compliance issues, right? Right. So you have to do that. So a little bit, a little bit of a of a situation to figure out. So I'll tell you all kind of the the little pathways I try to go down to open my endoscopic services and to also kind of make it streamlined for patients. So, you know, traditionally in traditional GI practice, referring doctor sends directly to the endoscopy center for like a screening colonoscopy, right? Don't they see the doctor ahead of time, hardly see the doctor afterwards. It's all about insurance reimbursement and you know, you know, getting reimbursed on the patient's insurance preventative plan or yeah, you know, you understand. Yeah. So anyway, so in this model, like I had an option. I could open up my own endoscopy center that was direct cash pay only. And I did start thinking about this, to be honest. And I got a consultant and we started to do a pro forma. And he was, he helped a lot of endoscopists get up and running in the past. And he's just like, Emily, I think, I think you're gonna need to contract with insurance. I don't really think this is, you know, gonna work all cash pay. And I'm like, well, but that's the whole the whole point. We want to like be transparent, you know, no, don't have this kind of questionable surprise billing afterwards. I just want to, you know, make it easy on patients. So then I considered being employed at a facility where patients would pay me my consultation fee, but they would use their insurance for their endoscopy services. Also, you kind of get into a murky, murky situation there with Medicare I doubt and like compliance issues, and just generally, like I'm trying to provide a high level of care, like high quality, like high touch. And that doesn't usually happen in such a center. Like a patient wants to be scheduled on Monday. No, can't schedule on Monday because whatever reason, right? But I'm like, yeah, but of course I could do it on Monday and the patient needs it that day. That didn't quite work out. So where we ended up was kind of a hybrid model, which is really nice right now because the patient will pay me their the professional fee. And then at the facility, they have an option where they can use the cash pay route. So, you know, a little bit of backup. You have to kind of have a partner that kind of is willing is willing to work with you this way and sees the benefit of it. So again, hybrid model, patient pays me the professional fee. They could pay cash or they use their insurance for for the rest of the charges through the facility. Facility fee. Pathology, uh, anestige. I mean, then they feel good. They've been, you know, they have insurance, they've been paying their premiums, they can use it still, but also, you know, they get me. And I'm on call for them, and they can take pictures at the grocery store when they're buying their clear with goods and ask me questions. And so it's this like higher level of touch for the concierge model. So I can tell you, like of all the patients that have come through, everyone's done the hybrid route. Nobody does the additional cash pay through the facility, at least of the of the clients that have come through so far.

SPEAKER_00 9:34

I mean, it's it's I think so. We even have a high deductible plan. So we have uh, you know, we use it for some things, we don't use it for other things. It just depends on what it is. So I get it. You know, and a lot of our listeners, we actually do have several practices that we do billing for that have a cash side of their practice, whether it's completely carved out and it's cash pay with different positions. There's kind of a couple different ways. There's VIP memberships that the cat or the insurance-based practices do that have like additional services that are typically not covered. And so they you do have to be careful. And Doscoe gets a little bit prickier just from a procedure perspective. For some of this other stuff, it's truly not covered. So it's a little bit cleaner for them. Yes. But yeah, I mean, it's and I think it comes down to what do you d derive joy from? Like obviously, with your eye from your working genius, like you like to invent, you like to create, you like to create these solutions for people. And so you had the ability to create this practice that made sense. But I and I think whether you've got an insurance-based or you're trying to figure out, okay, what do I do next? How do I drive joy out of things? Identifying uh, you know, again, where you where what it is that you enjoy doing and and then how do you want that to look financially? But we have practices that do lots of creative options. We even have one, she's a podiatrist, but she's got this incredible nail salon that is tied to her practice. Cool. That's uh, you know, it's not an inshar, it's just it's literally it's like a nail salon, and she's incredible, and so she's got a nail salon. So you know, and it works great because she's seeing people with feet all day. And so what do we know? Feet and they go to the nail salon and they've got special services at the nail salon more than just like you know, a pedicure. But it's just really cool to see physicians niching out what they enjoy and then how to get paid for it, not in a like a salesy way, but just in a, you know, I'm providing a service, I'm providing value to my patients. How do we get reimbursed for that? I just I think that that's at the end of this, right? You don't want to work 30, 40 years, whatever it ends up being, and not like what you've built.

SPEAKER_01 11:42

Oh, yeah, totally. You're you're right. So yeah, I tend to definitely focus on like, what do I derive joy or how do I have a client feel better, right? And then you're like, okay, but like then also how do I use that to get paid or support my business or pay my office manager or even myself, right? Because that was definitely a period of time where I wasn't taking, you know, I didn't take any any, I didn't have any income, any salary, right? So yeah, you die, I definitely, you know, have these ideas, and then I have to kind of think through them. But like, for example, you know, at my MI clinic, so when I was in traditional GI again, lots of colonoscopies and endoscopies didn't really talk to patients much about anything that was related to their gut health. For example, their metabolism, how they process their food and their glucose swings and their weight and their nervous systems, and you know, just they're even their microbiome. Like didn't talk about it, right? Didn't have time. Vitamin replacement went to primary care, didn't have time. So all of that goes into a patient's concierge package. And I have them fill out a like a my almost like a My FitnessPal. It's like a health app every day. I look at their protein fiber ratios. I have them do a body routine. Yeah. Oh my gosh, like the protein and the you know, uh things, all the health marketing out there for all the like fiber products. I'm like, this is what I have including an explosive diarrhea. So yeah, like it's it's just been so interesting to like, that's the idea. And then how do I, you know, make sure that I'm covering the costs and getting a margin and making sure that this is a viable company. So I found right away, I was trying to market a lot on social media and you know, via website and email marketing initially, but I found I wasn't getting any traction traction. So I'm like, I just gotta go out and get in front of people. So I either connect with them or there's a lot of primary care here in Colorado or they they find me. And that was the case here. And so I drove from I'm in Boulder County. I drove to drove to Denver and did that much. You were like hitting the pavement. Yeah, you gotta hit the pavement. I feel like at least that's what I initially has really helped with the momentum of getting a client into my clinic. Three years of this type of stuff, there's been a lot of, a lot of like, well, this isn't quite working. I'm gonna I'm gonna change it.

SPEAKER_00 14:21

Well, and I think we we have that. I was just it's terrifying to do that. And that like I've I just find it so cool to see physicians who have made these journeys of, okay, I've done traditional physician practice, but then to be doing these really cool, creative, imaginative things that get to use a different side of our brain and different skill set, it's just really cool.

SPEAKER_01 14:44

It's really cool. And like one of the things I was thinking about. So after I left my traditional private practice gastroenterology group three years ago, where I basically only did colonoscopies and never really talked to people, I just did colonoscopy, covered overhead, you know, did what I needed to do to survive. But I started going to these meetings, like almost like trying to look for like where I fit in. So I went to this women in medicine meeting that was founded by one of our GI societies. And I went there and they had all of us lady docs take a personality test, right? Working genius or something like that. We just did six working types genius. So I'm in this group of all these women, a lot of them are like rising up in academics, and you know, we're all like trying to figure out a way to be leaders and and do what we want to do. So, you know, I'm a little bit of an oddball in this group because like I had just left my practice where I was owner and shareholder and medical director, and that's it. I'm kind of like, yeah, I'm kind of gonna start my own thing. But anyway, so I take this test and I score like high on like the innovator and the tenacity uh-huh. I card and I'm IG, by the way.

SPEAKER_00 15:58

I'm galvan I'm I and then I'm a galvanizer. Yeah, G is G is my uh with my I. So you're an IT, yeah.

SPEAKER_01 16:06

So I was I was a little bit disappointed. And I'm like, but what are about my discernment and wonderment and all the good things that make you a good doctor and looking at a complex clinical picture? I'm like, have I not been doing what I'm supposed to be doing like all my adult life? And then I already kind of had the idea to like open this gut health marketplace for women called gut CRX, but I was like, then I was I turned it around, like, you know what? This is where I'm supposed to be, like in regards to you saying being creative. Like, I haven't been able to be creative. I haven't been able to like, you know, re-re-start the wheel or re-re-change the model. And this is like what it made me excited and made me want to like be a productive working person. So that was one of the things I did initially, which I already had the idea to to move on. But yeah, going back to deciding like when to move on, like it takes you a while because it's so much easier to just keep going with you know your your infrastructure, and especially when you're in a great financial situation, right? You're just like, well, of course, why wouldn't I just slug out like this for the next 20 years? But I think when it starts hitting you personally, like it hits your family, like you just and then you're just in like for whatever reason, like your head comes up and you're like, I haven't been doing what I'm like, what makes me what gives me joy, which is I guess what this working genius type personality test is for. Like, what what do you do to what do you drive energy from?

SPEAKER_00 17:41

Yeah, I like drive energy from thank you. Yeah. I mean, and I think it's funny, w the table group, which comes and does like these lead sessions, they came and they were talking about this and they had a CEO come and he was sharing his story. And he was like, he had developed such good competencies in things that did not derive him joy that he spent 15 years of his life doing parts of a job that were not part of his like top working geniuses. And he says, if I can tell any of you what to do, he's like, it's to go back and do the things that actually are are deriving you joy.

SPEAKER_01 18:15

I'm a little bit fall forward. Like, that's how like I figure out and learn. You know, there's risk with that, right? And yeah, totally. So I guess that's that's uh why we're on this independent position podcast. That's why we're here.

SPEAKER_00 18:30

That's why we're here. Well, and for the listeners, uh, we are talking about the six uh working types of genius. I'm butchering that title, but it is uh by Patrick Lincioni, and uh he's got a whole suite of books. I've actually talked about him and I've talked about this as a topic in past uh stuff. So you guys check that out. Now let's take you back to the beginning, whether it's the first 18 months of this practice or your other or your traditional either one, because I think the uncertainty is the same. Like if you were talking to a practice that say is either expanding or they just started a practice or they're starting something new, like how do you how do you manage like the uncertainty and that I don't know what this is gonna look like? Or like how do you manage that personally?

SPEAKER_01 19:18

Got it. Yeah, I guess like like I I kind of like lean into the uncertainty. Like, you know, I have the idea in my head, and maybe that's the personality thing, and I'm just like, you know, I I I know what I want it to be like, and then I write down the steps of how to get there, or you know, figure out the steps of how I could get there. Definitely you have to talk to people about that, those ideas. You have to have yes, you have to have somebody else look at your ideas, right? Because with the whole process, there's risk, there's financial risk to yourself. And I had a little bit of a buffer because I just took all my money out of my previous investment. And so I I, you know, put it aside for you know, my my own, my family, of course, but my projects, like my projects, which I hoped would, you know, lead to more growth in the future as well. So I think talking to a lot of people and networking, I had to do a ton of reaching out on LinkedIn, talking to heads of compounding pharmacies, talking to other doctors who had gone out on their own. Initially, I was kind of like leaning towards more of doing like opening up as more of like an integrative type of wellness practice. And after talking to folks that way, I'm like, you know what? Mo, it's a little more concierge. That's what I'm going for. A little more like high-touch concierge service. So, you know, it's it's a lot of trial and error, but it it's totally worth it. And there's been a lot of learning that has happened, especially between the marketplace and the in-person clinic, that, you know, even when things didn't work out or I wouldn't have done it again. Like I still learned from that process. So you have to, you know, have to go through a little bit of of not necessarily suffering, but a little bit of that in order to to to get, you know, to the to the joy.

SPEAKER_00 21:18

Yeah. I don't think you come out with an idea and we're like, oh, it's fully baked, we're just gonna be successful from the get-go. Like you're gonna get dogs and bruises and things that worked and things that didn't work. And so it takes a minute to get it all figured out. And again, whether you're doing an insurance practice or cash-based practice or hybrid practice or creating a marketplace like this, which is in and of itself fascinating. Like your website is beautiful, by the way. Yeah, like it's a really unique idea. And again, for the for the listeners, we'll have links to everything in the show notes so that you guys can check out the the her websites uh on both ends. I know our listeners are often a lot of physicians, so they can refer patients to guts. Or if you're in the Denver or Ohio area, look for other types of telemedicine and in-person services. You know, I I think it also gets a little lonely a little bit. You know, you've got a physician, then you've got a female physician, then you've got a female physician founder. It's just like you've niched down into there's not a lot of us. Yes. And even for the male listeners who are listening, and you are a founder, there's just not a lot of founders in general who have been in healthcare. And so it's cool to see. I feel like we're seeing this circle back. I feel like, you know, 20 years ago it was the circle towards employment. And now we're seeing that circle toward towards founders and a creative and interesting products or ideas or things that really solve the patient's true issues. I'm even seeing it in corporate where I'm starting to see more physician, physicians who are actually leading service lines, which is actually really cool. That is cool. It is, it just, I think people are starting to recognize then the need for clinical leadership. So it again, it's it's not easy.

SPEAKER_01 23:02

Yeah, I hear you. I know it doesn't get a little lonely. And um, you know, any lady gastroneurology doctors out there, my goal, I think I told you this before the uh in our pre-meet, that it is to get in all the states. So to even have like a local in-person clinic in other states, and then a that lady also helping, that lady doc also helping with the marketplace. That is my my ultimate mission.

SPEAKER_00 23:27

Awesome.

SPEAKER_01 23:28

Is is to branch out. And so I know there's some lady GI docs out there that have concierge practices like mine. But you know, you kind of do proof of concept locally, and then you know, that that that will be my next, my next step.

SPEAKER_00 23:43

I love it. Now, before we go, before I let you go, what would you think is like one thing that maybe you got wrong that cost you either time or money that, you know, has been like an aha moment for you.

SPEAKER_01 23:55

Well, I I sort of we sort of hinted on this earlier. So I put a lot of time and investment into my website. So it's the website is sort of built as like WordPress, e-commerce, and custom development.

SPEAKER_00 24:10

Yeah.

SPEAKER_01 24:11

And I put a ton of time and investment in there. And while I learned, like I can do, I can do things I never thought I could do uh with building a a web page or with e-commerce solutions. But now, like I feel like if I had thought about, oh, I'm going to go back to in-person practice, I would waited or not not done such a detailed, I guess, build. Yeah. And especially now with AI and like just how you can like build a website so quickly. I'm like, oh my gosh, like I can't believe I I did that. But at the same time, it's really great. And if I have any physicians join, they'll see how like lovely it is on the dashboard. Like I, you know, the patient has our dashboard, I have our dashboard. And so, you know, I think I think I would have held back on that and like put more investment into the in-person practice part of it, the the direct specialty there. Yeah.

SPEAKER_00 25:10

You know, again, where you were three years ago versus where you are now. You know, it's like you learn things. I mean, it's funny, we've changed our website twice and now we're looking to do it a third time. And I'm like, really? I mean, we're doing it in an in in not a fancy way, but but then there's all the SEO that goes with it.

SPEAKER_01 25:27

So, you know, no, there, and that's hard to the AI SEO, right? Like even like the Google, the Google searches anymore.

SPEAKER_00 25:37

I know, I know. So you do have to be careful when doing all of that maneuvering, and that's I'm stuff I'm learning right now. So I hear you. I know, I know.

SPEAKER_01 25:46

You're like, but I but I asked somebody to like make this a searchable whatever word, and now I have to figure out how to do it through AI.

SPEAKER_00 25:56

Yes, yes. Claude does answer a lot of those questions really well. I will say that. And that was a nice hire that we did this year was somebody who she she's amazing. Her name's Lucy, but she does all the marketing and everything, and she's great.

SPEAKER_01 26:07

And she knows she knows how to do do it with Claude.

SPEAKER_00 26:10

She's very techie, and her her partner is in app development. So he also is very techy. So it's just helped us navigate that because it isn't easy. No, but none of business is easy. So I guess it's just figuring out one step at a time. So well, this is awesome. This was so good. Okay, so how do people find you? Obviously, I'll have your websites in the show notes, but how do people find you if they're like, hey, I have patients who would love Gutsy RX, or I'm really I'm a GI doc or I'm a concierge doc and I'm interested in learning more about you know your GI practice. How do they find you?

SPEAKER_01 26:42

Yeah, two best ways. So Gutsyrx.com. They can shop or they can find the concierge uh website part. And then all my all my handles are at Gutsyrx underscore gut health. Okay. So I I love Instagram if anyone wants to follow.

SPEAKER_00 26:58

Yeah. We'll put your Instagram in the in the in the in the uh show notes. So that's great. I love it.

SPEAKER_01 27:07

Yeah, I'm sure I'm sure a lot of physician founders told you that have told you that they didn't have social before they started their business. So I'm one of those people. I didn't I didn't do it. I didn't know.

SPEAKER_00 27:16

I have 15 followers, so I'm not one. I we don't, that's not where we live either. So I get it. Well, it's been a pleasure to hang out with you today and get to know you. So thanks for coming and sharing your story. It's always nice to have other physicians who are doing really cool things. Come on. So I hope you have a great rest of your weekend and good luck with the beginning of school.

SPEAKER_01 27:35

You too. Thank you, Heather. Talk soon.