Building an IR practice from scratch: rate data, location, and the proforma you can’t skip

Starting an IR-led OBL is more accessible than most realize. Here’s the rate research, market analysis, and modeling framework before you sign a lease. Most of us get hung up on the clinical build-out—the C-arm, the patient table, the recovery bays. But the reality is that the financial architecture you design is just as critical as the physical one. A successful proforma isn’t just a spreadsheet of projected case volumes and reimbursement rates. It’s a strategic plan that leverages every structural and tax advantage available to a capital-intensive medical practice. Before you can accurately model your five-year profitability, you need to understand the powerful financial levers that can dramatically reduce your tax burden and accelerate your return on investment. These aren’t minor tweaks; they are foundational decisions that can change the entire economic picture of your practice. For a broader look at the landscape, you can explore our full collection of IR free tools and OBL resources.

First-Year Tax Shield: Section 179 and Bonus Depreciation

When you’re launching an OBL, your largest initial outlay will be equipment. An angio suite can easily run $1.5 to $2 million. Ultrasounds, C-arms, and other necessary gear add up quickly. Most physicians think of this as a capital expense to be slowly depreciated over many years. This is a critical, and costly, misunderstanding. The tax code provides two powerful tools to accelerate these deductions into the very first year of operation: Section 179 and bonus depreciation.

Here’s how it works. Section 179 of the IRS code allows you to treat a massive chunk of your equipment purchase as an immediate operating expense. For 2026, the limit is $1.16 million. This means if you buy a $1.5 million angio suite, you can deduct the first $1.16 million directly from your practice’s taxable income in year one. This isn’t a phased-in deduction; it’s an immediate, dollar-for-dollar reduction of your profit.

What about the remaining $340,000? That’s where bonus depreciation comes in. For 2026, bonus depreciation is set at 60% for qualifying new and used equipment. This allows you to deduct an additional 60% of the remaining cost in the first year. The combination is staggering. On a $1.5 million purchase, you could potentially deduct over $1.36 million in the first year ($1.16M from §179 + 60% of the remaining $340k). This creates a massive paper loss that flows through to the partners’ personal tax returns, sheltering other income and dramatically improving the cash-flow profile of the business in its most vulnerable early stage.

The trap most physicians fall into is failing to plan for this. You must place the equipment “in service” during the tax year to claim the deduction. Signing a purchase agreement on December 28th doesn’t count if the suite isn’t installed and operational by December 31st. This requires careful coordination with vendors and your construction timeline, but the tax savings are too significant to leave to chance.

The QBI Workaround: Using an Equipment Leasing Company

One of the most significant tax benefits for small businesses is the Section 199A Qualified Business Income (QBI) deduction, which allows owners of pass-through entities (like LLCs or S-corps) to deduct up to 20% of their business income. However, there’s a major catch for physicians: medicine is classified as a “Specified Service Trade or Business” (SSTB). This means the QBI deduction begins to phase out once your taxable income exceeds certain thresholds (around $394,000 for single filers and $787,000 for joint filers in 2026). For most successful IRs, this valuable deduction is completely unavailable.

However, a well-structured OBL can create a path to reclaim it. The strategy involves separating the clinical practice from the high-value equipment. You form two entities:

1. PracticeCo (Your OBL): An S-Corp or LLC that performs the clinical services, employs staff, and bills for procedures. As an SSTB, its income will not qualify for the QBI deduction for high-income owners.
2. EquipCo (Your Leasing Company): A separate LLC that owns the angio suite, ultrasound machines, and other capital equipment. EquipCo then executes a formal, fair-market-value lease agreement with PracticeCo.

The rental income generated by EquipCo is generally *not* considered SSTB income. It’s rental income from a commercial leasing activity. This means the net rental income (rent received from PracticeCo minus depreciation and other expenses) flowing from EquipCo can be eligible for the full 20% QBI deduction, even for high-income physician owners. This requires careful planning with a CPA who understands the aggregation rules under Treasury Regulation §1.199A-4, which dictate how commonly-owned businesses must be treated. The entities must be properly separated, the lease must be commercially reasonable, and all formalities must be observed. This isn’t a DIY project, but it’s a standard and powerful strategy for capital-intensive practices to capture a tax benefit that would otherwise be lost.

OBL Ownership Economics: K-1s, Pass-Throughs, and Paper Losses

When you own an OBL, you’re no longer just a W-2 employee or a partner in a group that bills for professional services. You’re the owner of a capital-intensive operating business. This fundamentally changes your financial and tax picture. Instead of just receiving a salary or a draw, you’ll receive a Schedule K-1 from the partnership or S-corp. This document is your share of the business’s profits, losses, deductions, and credits.

Most of us were trained to think of business losses as a bad thing. But in the early years of an OBL, “paper losses” are a powerful financial tool. As we saw with Section 179 and bonus depreciation, your new practice can generate enormous deductions in its first year. It’s entirely possible for a brand new OBL to have a net operating loss on paper, even while being cash-flow positive. This K-1 loss passes through the entity directly onto your personal Form 1040, where it can offset other income—such as your spouse’s W-2 salary or income from other investments. The result is a substantial reduction in your family’s overall tax bill, which effectively acts as a government-subsidized boost to your OBL’s startup capital.

Understanding the distinction between active and passive participation is also critical. To deduct these business losses against your ordinary income, you generally must meet the “material participation” tests defined by the IRS. For a physician-owner who is actively managing and working in the OBL, this is usually straightforward. The trap is for passive investors. If you are a silent partner in an OBL and don’t meet the participation thresholds, your ability to deduct these losses may be limited by the passive activity loss (PAL) rules under §469. This is a key structural consideration when bringing in partners who may not be working in the center full-time.

Cost Segregation: Front-Loading Your Building’s Depreciation

If you decide to build or purchase the real estate for your OBL, you unlock another layer of tax-advantaged planning: cost segregation. Normally, a commercial building is depreciated on a straight-line basis over 39 years. A $3 million facility would generate a depreciation deduction of about $77,000 per year. It’s a slow, steady write-off. Cost segregation is an engineering-based analysis that shatters this timeline.

A cost segregation study meticulously identifies all the components of your building that are not strictly “structural.” This includes things like specialized electrical wiring for the angio suite, reinforced flooring, lead shielding, custom plumbing, cabinetry, security systems, and even exterior landscaping and parking lots. Instead of being part of the 39-year building, these assets can be reclassified into shorter-lived categories—typically 5, 7, or 15-year property. A typical study on an imaging center can reclassify 25-30% of the building’s total cost into these shorter-lived buckets.

The impact is dramatic. On that same $3 million building, a cost segregation study might identify $800,000 worth of 5, 7, and 15-year property. Thanks to bonus depreciation (which also applies to these reclassified building components), you could potentially deduct a huge portion of that $800,000 in the very first year, on top of the standard depreciation for the remaining 39-year structural component. This front-loads years’ worth of deductions into year one, creating another massive paper loss to shelter income and supercharge your practice’s cash flow. It’s an essential step for anyone building or buying their own facility.

The Proforma: Where Rate Data Meets Tax Strategy

Building a defensible financial model—the proforma—is the ultimate test of your business plan. This is where your assumptions about case volume, payer mix, and reimbursement rates collide with the realities of your cost structure and tax strategy. Most physicians start with the revenue side, which is critical. You need to know what you’ll be paid for a CPT 36247 or a 37221 in your specific geographic area by your top commercial payers. This is where having access to real-world CenterIQ procedure rate data becomes indispensable; guessing at reimbursement is a recipe for disaster.

Once you have a handle on revenue, you model your expenses: rent, staff salaries, medical supplies, insurance, and financing costs for your equipment. But the proforma can’t stop there. A truly accurate model integrates the tax strategies we’ve discussed. Your five-year cash flow projection will look radically different when you factor in a $1.3 million equipment deduction in year one. Your net income and partner distributions will change when you account for the 20% QBI deduction from your equipment leasing company.

This is where many physicians get overwhelmed. The interplay between clinical operations, payer contracts, corporate structure, and advanced tax planning is complex. It requires a multidisciplinary view that most of us never received in training. This is precisely why engaging experts early is so important. Working with an ASC/OBL feasibility advisory team can help you pressure-test your assumptions and build a proforma that stands up to the scrutiny of lenders and partners. They can model different scenarios and ensure your financial foundation is as solid as your clinical skills.

Building an OBL from the ground up is one of the most professionally and financially rewarding paths an interventional radiologist can take. It allows you to control your clinical environment, deliver patient care on your own terms, and build significant long-term equity. But success hinges on getting the financial framework right from the start. By understanding and implementing these foundational strategies, you move from just being a clinician to being a sophisticated business owner. If you’re ready to model your own practice, you can schedule an OBL feasibility call to walk through the numbers.

Free GigHz Tools That Pair With This Article

Three free tools that complement the material above:

• ACR Appropriateness Criteria Lookup — Type an indication or clinical scenario in plain language and get the imaging studies the ACR rates for it, with adult and pediatric radiation levels. Built directly from 297 ACR topics, 1,336 clinical variants, and 15,823 procedure ratings.
• GigHz Imaging Protocol Library — A searchable library of 131 imaging protocols with the physics specs surfaced and the matching ACR Appropriateness Criteria alongside. Plain-English narratives readable in 60 seconds, organized by modality.
• GigHz Radiation Dose Calculator — Pick the imaging studies a patient has had and see total dose in millisieverts (mSv) with comparisons to natural background radiation, transatlantic flights, and chest X-rays. Useful for shared decision-making.

Reviewed by Pouyan Golshani, MD, Interventional Radiologist — May 21, 2026