Good evening, everybody. If you're on the East Coast, it's early evening today, the 10th of May. If you are Central, late in the afternoon, and ditto for West Coast, moving into the late afternoon. I appreciate everyone for hopping on board with what essentially will be our wrap-up of the Medical Practice Operations Business Fundamentals modules. This is Module 8. I think technically there are 10 modules because, as you'll recall, we parsed out a couple of those that warranted a lot more discussion. And so I have an hour slated tonight, but if it goes over and there has to be additional conversation, I'd be delighted to entertain any other questions or comments or thoughts. And certainly if you have pushback or situations that don't get addressed during tonight's discussion, certainly you can reach out to me via my cell number. That's the easiest way to get me. You can shoot me a text at 678-333-3419, or you can call and we can try to connect at a later date and time. I will preface tonight's discussion by making sure that everybody understands very clearly that the answers to the questions that were submitted to me are not one size fits all. And I've talked about this in prior webinars in as much as what happens in Atlanta, Georgia, where I live, is not even what happens in Valdosta, Georgia, which is down at the state line between Florida and Georgia. Likewise, what happens in New York City is not necessarily what happens in the middle of rural Nevada. So while 80% of what I cover, I think is applicable in a broad sense and fairly, if you will, in a vanilla sense, the other 20% really is region or locale specific. It's based on your demographics of your patient population. It's based on your access to the health system. If you're rural, are you shipping people 60 miles to the nearest tertiary center, those types of things. Likewise, if you're in a position where you're doing contract negotiations with a payer, your leverage and latitude in your market really is what matters to you. Again, whether it's Atlanta or Valdosta, Georgia, that does make a difference in your ability to negotiate. But we'll talk a little bit more about that later. And I'm happy to open the floor after we get through the questions that were submitted. If you've seen the other WebExes to date, here is the appropriate disclosure information from AOA and AOIA. Again, a disclaimer covering the same as we've seen historically. This is a little bit about me. If this is your first WebEx, in a nutshell, I have spent the first half of my career running private practices. I got involved in a private equity funded, venture capital funded, what is now kind of the PE space as private equity groups are buying practices. I'm involved in a venture capital backed business and practice management company in the 90s. And then I got into consulting in the early 2000s, mid 2000s, and have been doing that ever since. You can see I belong to the Health Financial Management Association, Medical Management Association, and the American Health Board. So just a brief summary of where we were and where we are tonight. Again, this is essentially 10 modules where we discussed employment opportunities from health systems to private practices, private equity and employed models, how that looks and is managed. We went on to discuss in module two, the finance components, which we split up in part because the first finance piece was really to cover differences in P&Ls and to give you a facile understanding of just a basic cash-based business versus accrual accounting, which is what health systems generally run on the accrual and private practices run on cash. There's a difference in the timing, which we won't get into tonight. And then module 2A was really about different physician compensation plans, where we were, a little bit of history, where we are, kind of where we're heading. And then we split out rev cycle into two big buckets because such an important component in the, I hate to say in that practice of medicine, that sounds really awful, but in the sustainability of healthcare entities, let's put it that way. We did in module four, a very topical, some of the legal third rails, some of the hot wires with regard to healthcare. And if you recall, if you went through module four, a good deal of module four was really talking about the business of healthcare and all the normal legal things that go with that, like ADA, when you're hiring HIPAA related stuff. But then we also got a little bit into fair market value considerations and antitrust considerations. Again, very topical. I'm not an attorney. I know enough to be dangerous. So with any concerns relative to the legal piece should seek qualified healthcare legal counsel. Then we looked at the operations components of medical practices, and then a little bit on healthcare IT. And then we finished up the formalized webinars with a discussion about coding and CPT codes and their value and what they mean. So tonight we pull together all these 10 modules to a little bit of a Q&A and some follow-up. And I did receive questions that we'll cover, and then I will open the floor up at the end. If anyone didn't get to submit a question or my responses elicit further questions, I'd love to hear from you and have that discussion. So what we're looking to do here is follow up on modules one through seven via the questions, provide a little bit more insight and clarify where that makes sense. And then a simple understanding of the prior modules. Again, this is a one size does not fit all. Healthcare is truly local. So Q&A and follow-up. If you've looked at the other or listened to them, you haven't seen this, but if you downloaded and gone through the other modules, I think just about all of them, I use this sort of tired out patient flow model because I want to make sure everyone understands that it's always worth noting all of these things that are delineated in this graphic. In this graphic, the verbiage is basically about revenue cycle. But all of these pieces interact in the delivery of care, and they all impact quality, cost, reimbursement, physician compensation, the value of the practice, all of those things. And so as we talk about or answer some of the questions, think about how those how those interact, what the interplay is between the various pieces on the clinic flow diagram, if you will. So the questions that I have, hopefully there's nothing grammatically wrong with them. I just grabbed and dropped them in. The first question that I'll address is someone had asked, is it better to hold claims in January and February for patients with deductibles? And then I guess there's a look like it was a part A and B to that. Is it more beneficial depending on the claims for certain physician specialties or if they're having a procedure in a facility? And is it best to utilize a credit line to cover expenses until revenue does come in for those claims that were held? So for me, as a former operator and as a now advisor and partner with health systems and private practices, I would say that that boils down to, and I don't want to punt on this, but I'll tell you why. I would say that boils down to the practices call on how they want to manage their finances. I wouldn't do that because most patients now have deductibles. I mean, generally speaking, as long as I've known they've had deductibles, the question is how many have high deductibles. And I guess my concern with using the credit line to, in lieu of billing all those and then hoping patients come back in and they've met their deductible, it just looks like a lot of kind of going around your elbow approach to revenue cycle. And so instead, I think what I would like to see done is very aggressive front-end management, knowing that patients are going to come in, their deductibles are going to be reset. And what should happen is when the schedules are made, the staff should go out a few days ahead of time and verify online the patient's eligibility, their current insurance, get those loose ends tied up up front so that patients know, right, you level set, not only will you get your money, but you level set with them what the expectation is. And candidly, patients with high deductible plans or have any deductible should be expecting to pay out of pocket. And then the flip side of that is, let's say you collect more than you should have, you simply need to go back and refund the patient the money. By the way, I would not hold that money in a credit account for when the patient comes back in. I've seen that go really badly for some clinicians when patients don't come back in, don't come back into the office. And I will say I've dealt with a medical practice in the southeast that had several million dollars in patient credit balances, which is, I'll just say it's definitely a no-no. So in any event, I feel like if you're hyper aggressive, and I don't mean rude and mean, et cetera, but if you're hyper aggressive in your structure and your collection processes, you should be able to collect what you need to from the patient up front. For me, I usually only use my credit line if I've got to fill gaps. Decidedly, things get a little slower in January, February. Money in January should be flowing through from your December claims. So you may be late January into February, maybe a little bit in March where things are slow. But I would, for me personally, I would only use the credit line to plug gaps and manage. If you are in a C-corp, more than likely, again, not an accountant, but I've run C-corps. If you're in a C-corp, usually what will happen is the accountants will either cash out all the dollars that are left and bonus out the shareholders. They may hold some aside that carries over. So you a lot of times can start off with a zero balance or enough money to pay the first week of bills. So that is, again, an opportunity where you may want to use the credit line a little bit. But I think being aggressive on your revenue cycle procedures and policies. So when 1-1 kicks in, you're ready to go. Relative to certain physician specialties, a little bit hard to answer because if you're in a 20-doc group and you've got four different specialties, that's a lot of extra management. And the question would then be, do you have the staff to be able to manage that? Then the question is, is it facility-based? Are you doing these procedures in a surgery center? Because that comes in play vis-a-vis the collection. So again, I would look to the patients that validate and verify their insurance. Sorry to use alliteration, but there you have it. And again, my answer in the second bullet is possibly, but why not? Why not aggressively manage upfront? That's where everybody is. Everyone has to deal with the same thing. The next question is, can you limit the number of patients you see with specific payers? So the crux of this question is Medicare pays bad, Medicaid pays worse. I will tell you, there are some states where there are commercial insurance companies that are 95% of the market where Medicare is the best payer in the state. So I'll leave that at that. But nonetheless, that's a philosophical decision. I would leave it up to you internally in your practice, your clinic to decide how do we want to manage this? Do we do, maybe we get a couple of Medicare rechecks in a day or one new patient or what have you. I will tell you, I know Mayo Clinic did this same thing a few years ago. I don't know what the ramifications were, but certainly there could be a little bit of a local public relations nightmare in your backyard if people hear that you're turning away Medicare or you're giving preferential treatment to commercial payers who theoretically reimburse more than Medicare. So this is just, sorry, I just threw this in. Y'all have seen this before if you've been in the other webinars or WebExes. This is just purely, here's what we're going to do. The revenue cycle begins before the visit. This speaks to a little bit, harkening back to the first question. It starts before the visit. We need to be prepping for this before 1-1-2000-XX, 2024-2025. Eligibility, insurance check. We should never say to the patient, do you still have the same insurance? We should always get proof of card. Some of the noise I go through when I go through my annual visit at my primary care drives me insane because I fill out the same things every day or every time I go in. What I would hope they would do, which seems better, is kill less trees, maybe have a questionnaire that's something like, aside from collecting the insurance information and that stuff where you want actual physical cards scanned into the system or proof of the insurance coverage. Go through my family history. Has nothing changed? Nothing's changed. Hit an end. You don't have to fill everything in again if nothing's changed. But anyway, I digress. The next question, if I have no billing or practice major experience, how do I know that I'm hiring the right PM or administrator? How do I know what they say about billing and coding management? A full revenue cycle is right. I certainly can't risk hiring. So if you're concerned, find a qualified external source, and it can't be your cousin, Jim, who runs the steel mill down the road. Healthcare, I've said before in my other WebExes, healthcare is complicated. You need someone who understands healthcare. You don't have to be a PhD teaching at Emory or whatever, but they need to have a facile understanding of the functionality of a medical practice and what goes on. Now, to the billing and PM experience, a little bit tricky here. If you're a large practice, and by large in the private space, I'd say probably 10 or more. When I think large from my client perspective, generally that's 800, 200. If you're in that situation, you've got an experienced person who's running the rev cycle and or managing the coding, documentation, compliance, doing some internal auditing. If you have a two, three, four doc practice, it wouldn't be a bad idea to get an external person to come in maybe every six months or once a year to do an audit, to do education, and maybe you have them as a go-to if you have questions. There are certifications for CPC for being a certified procedural coder, CPC. There are also certifications for other avenues. I think there's a vascular one. Now, I had a CPC who worked with me before and she had a vascular coding certification as well because we're doing a lot of vascular and cardiology work. The how do I know what they're saying about billing and coding? Honestly, the clinicians need to get educated on that. I know it's painful and it's an awful piece of practicing medicine, but the reality is I don't expect the clinician to be an expert, but they need to get educated and have background and don't entrust the manager to know everything about everything. It's unfortunately very complicated and noisy in the coding space. I would say in terms of hiring a manager for the private practice, you can get some bulleted stuff put together. I could do it or you could look elsewhere. Basically, just what am I looking for? How big is my practice? What level of sophistication does this person need? Do they need to have had 10 years and an MBA? Those kinds of questions come into play when you're looking to hire a private practice manager. I will tell you this, on the private practice side, and I have said this previously, the struggle in private practice management is sometimes physicians will hire, clinicians will hire people who are the lowest cost asset. I would suggest to you what you want is someone who you pay well who does a really good job And by the way, good job also means putting in guardrails for those people So they know what their KPIs their their performance indicators are And you can manage them better and everyone understands that so I hope that answered that Never ending so the second question kind of ties in the first How do I know if I have an experienced coder that is staying up on never ending coding changes? The losing revenue piece I Don't understand that these be coding because coding You may have someone finish up your coding but the coding is predicated on the documentation so if you're getting let's just say if you're a clinician and You're submitting all level twos. You are probably missing revenue because a nine nine two one two nine nine two. Oh two Those if you think of coding for the E&M codes outpatient basis You should have a fairly Gaussian distribution of L curve on those Plus or minus so if you're building all level twos whether you're doing it yourself because your EMR assisted you in that decision-making or you do all the coding and your coding person or biller Submits a level two that may be on you as a clinician the coding people can only use what you've provided in your documentation That warrants the level of service so Get an experienced coder. So one of the CPC and or if you're in a specialty space somebody understands the specialty space They have some background. I would have someone vet them carefully to see if if they have the chops for the job And then then the rest of it is really on the clinician to stay up to speed as best as possible And I know that a lot of the subspecialty societies offer Acute level coding education for subspecialties, so there may be value in that The next question can you tell a patient you can no longer treat them or schedule appointments if they don't start paying the bills The answer to that is yes, you can You know in health care that's for a lot of people Not an approach they want to take because when you look at yourself as a clinician, it probably makes you feel bad but the reality is You need to generate revenue To pay the bills to pay your staff to have a life of your own maybe to pay back medical school debt, etc You can divorce a patient from the practice for clinical non-compliance and financial non-compliance and or There there are guardrails to those actions. So in other words, let's say Susie Q is not clinically clinically compliant She has CHF. She won't take her meds. You can't help her. She's getting wetter and worse You can say to her look you're not helping yourself. I can't help you But there is a process to that every state has a process if the manage that To divorce the patient you have to provide them a certain timeline and you have to provide them other Other Providers in the area that you can refer them to or that they can seek out So it can't just be a hard stop likewise with financial if you've been up front with folks. You've been treating them They're coming in. They're simply not paying their bills. You've tried to work out a payment plan You know, you've worked with them on outstanding debt, whatever the case may be You can divorce them from the practice. But again, they are there for reason it's for clinical care You have to apply guardrails to that action to ensure that you comply with your state's regulations relative to To divorcing a patient from the practice The next question is can you make it a Requirement to put a patient's credit card on file before you'll even accept them as a patient. I've noticed this in a site practices. It used to be acceptable. I think it's still acceptable. However you can't just use that as the piggy bank when they show up and they You know if this is one of those folks who has a who has issues with their bill You can't just start paying their credit card. So again, there there are Excuse me. There are processes and procedures in place that you have to file Notices to be signed off where they say hey, I understand that I will use my credit card on file to make this payment Next question. Is there a software that can scrub a claim or assist to code your level of service possibly based on DX or time. So the answer is Is law and I put my first EMR in almost 25 years ago all PM or excuse me all approximate EMR systems at this point have some sort of scrubber whether it's built-in or there's a clearinghouse That scrubs and looks at things In and they will they will suggest in many instances a Level of service that can be coded based on what you submitted However, the ultimate decision making relies on the clinician So if Medicare comes in and does an audit on you and you say well, you know My EMR suggested all level fives for this They're gonna look to you and say you signed off on this. That means you attest to the fact that you're a This should have been a level five and they could come back to you and say they all should have been level twos You owe us this much money Next question level 1 EM isn't accepted by any insurance payers right now I think I think that's specifically a 99201, but I think 211 as well. Generally speaking, that's right the reason there's pullback from the 201 is because 202 and 201 entail very straightforward decision-making versus 203 204 205 to 1923 214 215 That's the logic behind that. I think that also evolved under the Trump administration in an effort to Sort of What they said at the time was allow clinicians to spend more time with their patients less time at paperwork I don't know if that's accurate or inaccurate, but the answer to the question is I don't know if all insurance payers have done away I know a lot of them have Medicare has that means Medicaid has and oftentimes the commercials will follow suit and I know several commercials that are not accepting the level 1 EMS and basically Honestly, you walk through the front door. You're already a level one just about by definition. So kind of makes sense to me Next question, can you incentivize front-end desk staff to collect balances and co-pays? Can you give bonus to billing staff to meet a certain percentage of revenue goals, etc? The answer is yes to that as long as people are not being rewarded on how they code claims And you're not rewarding people again You're not incentivizing them to do anything wrong to bill inaccurately or commit fraud You're incentivizing them to collect co-pays to collect deductibles to help you tighten up the financial ship Otherwise known as a revenue cycle In in the clinic so bonuses can be made Predicated on you what you want for your revenue cycle outcomes again You you cannot incent people to bill certain levels of care or anything like that. It can't be based on the volume We collected 99% of the co-pays we were supposed to collect we had a revenue goal for the practice I mean you could have a revenue goal for the entire practice and then reward those folks who had Touches along the way that helped you get to that goal So there ways you can craft that build out your own measures metrics hunt some down and craft a plan that helps reward folks For contributing to your financial cycle The next question, how do you know if the insurance contract rates are fair or not how to know which ones to reject or negotiate on? Okay. This is a whole hour-long plus discussion and then some There's a lot of moving parts in this. So Obviously you can't in your market talk to other people about this You can't talk to other people about this and you can't talk to other people about this Obviously you can't in your market talk to other clinicians about what they're getting paid because that becomes an antitrust issue I think I mentioned this in my legal piece Legal module when we contemplated something akin to coke and Pepsi getting together and say hey every soda Can we sell every 12 ounce can is going to be $25. That's illegal You're artificially setting the market and you're not letting it be competitive. So that's one piece to this again. Not a lawyer There's nuance to that. If you're curious about it, ask a health care attorney What you have to do and understand about your your insurance contract rates is You you have to be able to understand your volumes of patients And historically all things being equal your coding accurately. What are you? Doing what so for medicare the assumption is going to be you have a lot of sick patients in medicare You should understand very clearly what cpts you performed on those patients On a broader macro level you should understand what percent of medicare is your business From both a patient volume and a revenue perspective because those won't be the same generally speaking And understand your commercial payers and I wouldn't go to you know Jimmy bob's five and dime insurance company because they probably are one percent of your revenue But certainly you should look at the big commercial payers in your market Maybe so it's medicare medicaid who you can't negotiate with but you can understand what they're paying um, and that's valuable when you negotiate with say blue cross blue shield or Aetna or united or cygna or humana or kaiser's? understanding What kind of quote unquote business you do with them is essential in helping you to understand when if and when you can walk away so for instance Um, i've got out here um I've got out here in the graphic one, two, three insurance companies and sorry I put medicare um as the payment on this and so what you can look at is Um, let's say insurance company one for a 99203. They're going to pay you 195. Well, that's 111 percent of medicare Is that good or bad? Well that depends because for if you're doing all level twos on medicare or on insurance company One's patients and they're paying you 230 or something absurd then maybe that makes sense. You have to look at your patient mix And it's arduous and painful But looking at all your cpt's will help you get to the right answer. So here you see we've looked at insurance one two and three Um, and you can see generally speaking. It looks like insurance company two looks pretty good Well again, if that's if that's jimmy bob's insurance And they're willing to pay you more because they want your doctors in their panel But you know, you're making four hundred dollars a year off them in your 10 million hour practice Yeah, take those but that's not going to help you impact the bottom line. So Trying to make the point with y'all that it's a it's a There are a lot of inputs and variables to it. Um, and You need to consider a lot of different angles your your market demograph Um the market penetration of so market demographic of patients market penetration on the payers Uh your level of competition. Are you a three dot cardiology group? In charlotte north carolina where there are 10 other 30 dot groups. You might not have a lot of negotiating leverage So those things come into play. So it's not really a one size fits all answer but certainly if the commercial insurance companies Are all competing and you don't have one that's market dominant. You should expect that they would be paying you 120 to 140 to 150 percent of the going medicare rate. That's just sort of A general prism with which to view this Uh, what is the benchmark for days in ar where do I locate these benchmarks? So kind of the functioning benchmark right now is Kind of 38 to 42 days in ar Um, that's fairly widely accepted I would suggest to you if you looked to different inputs It's not going to variate very much from that um the The question is, you know, if you're in a health system their days in ar may be a little bit mucked up So if you're in a private practice Where you can manage this and you're in cash basis Or even if you're in an employed network where the hospital owns you and they're in your billing um in accrual accounting You should be able to get to your days in ar Pretty easily even if you wanted to do it on your own in the hospital or health system didn't supply it The one caution I would have is you can make days in ar look really really good by Not collecting money. That's do the practice by writing off Differences in collections, so let's say a commercial insurance company owed me a hundred dollars um, they paid me 80 and my person who's posting the money writes the other 20 off because Whatever. I mean it happens so You want to make sure that you're calculating the ar? Um accurately and i'll give you an example. I had a 350 doc practice in the midwest Their days in ar Were they were doing about? 200 million dollars a year their days in ar were thought to be like 30 32 days and when I looked at the data, I said well, this is awesome, but Your cash is drying up. How is this even possible? I mean provided you're you're submitting big charges, which they were they were busy How can you be at 30? 31 days and have a A revenue issue. Well, they were calculating their ar all wrong And again another story for another time, but their days in ar ended up being about net net about 75 I think which is untenable, but it also shows why the revenues were were wrong drying up Give example of tabular format shows overstaffing In front staff and nursing staff. How do I determine and scale back? So I will tell you this just philosophically as a manager and as someone who's been managing people for 32 years Um, i'm not a big scale backer. I'm right sizing right hiring so for me I don't pull the trigger on hiring anybody until I have a very defined need and I know what i'm going to do with that person because you know when you when you scale back It impacts somebody's life in a financial setting and then probably mentally Physically, etc. So that's just a little management philosophy There are different ways to look at the staffing in the practice One of the ways which I put down here is you can look at different staff levels By by work now, you can look at it per 10,000 work overuse You can look at it per clinical ft. There are different ways to slice it, but they all should get you To write about the same Um number so in this and this is a real example for a group out west Um, you can see that their work per provider. They're a little bit over Uh, their total support staff based on this data. They're about 28 people over Uh clinical support staff based on this data. They were 16 over now when you look at that, you don't want to start firing 45 Five people the question is am I using those people efficiently because in this case when you when you peel back the onion They had a lot of ebb and flow of Clinicians, so I think they had 30 ftes, but like 60 60 clinicians So they had this imbalance of clinician versus staff. You'd have some days we'd have six or eight Clinicians in but you'd have full staff there. So so it's not a one-stop answer It's looking at all of the inputs And then for me, it's okay if I you'll just say i'm slightly overstaffed before I go in in Downsized folks. What can I do with the folks that I have? Um, how do I make this a more efficient business and make my life as a clinician easier? Um where I could maybe add five more patients and not feel it Uh that those are the questions to ask and then you know net net If you have to get rid of people for me, that's that's um, kind of the last resort Here are some benchmark, this is a Fictive thing. I just threw out there Um where this group is measuring the rev cycle. This could be part of an overall packet of financials that that are delivered to the executive committee Um, whether that is a five doc exec committee in a hundred doc practice or just managing partner In a five doc practice you should be privy to these things and understand what they mean You don't need the weeds, but you need to understand what they mean so that when this date is presented you understand What's going on and you can ask? Salient questions of your person who's managing this Likewise you should have these for office visits if you're a surgery practice how many surgeries are performed What our clinicians work our views are because those in the vacuum don't tell you anything Um, but mashed together on the whole they tell you a lot and it also helps you To analyze the business of the practice where they're going what's going on and it helps you to get to the root of of issues Benchmarking example of looking at the patient mix and seeing that surgery office is not ending up with surgeries, how do I collect this info?" So this is basically, I think if I'm reading it right, I have a surgery office whether it's one surgeon or multiple surgeons or what-have-you. I see a lot of patients, I'm not doing a lot of cutting. And why is that? So what I would do is understand clearly how many patients of mine or in the practice, so I'd look at if I have five clinicians, I'm looking at five different subsets of the greater whole. And I'm getting a patient, one out of ten I do surgery on, I'm happy with that measure, that's good. But Dr. Jim sees five patients and is cutting on four. Well is he getting more surgeries because someone perceives him in the community as a better surgeon? Or is it more surgeries and some of them maybe don't need to happen? Or does he have a subspecialty where, you know, there's a lot of demographic stuff that plays, there's a lot of decision-making on a clinical level, you know, when you're selecting surgery versus if it's orthopedic, you know, PT or something like that, that all comes into play. However, to get back to what I think is the crux of the question, if you're performing surgery, you should be able to look at your patients and figure out what percentage of those patients coming through the door you are performing surgery on. And then understand, if you're in a subspecialty, what that looks like vis-a-vis your subspecialty. So I think orthopedics is two surgeries on every ten roughly, but you have to forgive me because that's the number that sticks in my head and it may not be dead on, so don't run with it. But that's the kind of analysis that I would do. Section on marketing, how are you measuring how many patients came into an office, came into the office, came into the office as a result of different kind of marketing? I put up a little graphic, it's very rudimentary, probably no one runs print ads anymore. It's just to give you a sense of spend and value. Word-of-mouth is always your cheapest, least expensive method to market. So having a good reputation in the community, being a yes person when someone wants to refer in and not punting them, being responsive to referers, that goes a long, long way and costs you zero dollars unless you want to go out to dinner one night and do a case study with a referring doc and it cost you the price of the meal or something like that. When you're doing marketing, so to speak, so when I say doing, when you decide I'm going to market, I'm gonna market the practice, I'm gonna do whatever that is, what are you marketing specifically? Are you just gonna run a bunch of Instagram posts that say, hey, come to Joe Blow's orthopedic group, we do surgery. Okay, I mean, what's the end goal? What are you trying to achieve so that you can measure? You'll know when you got there or you'll know you haven't reached there. Have a cohesive plan and execution and KPIs so that you can manage all of the pieces along the way and understand what you're doing and then understand the value of the social media opportunities. Whether it's Twitter, Instagram, Pinterest, whatever you want to be on and push the practice. What are you doing? What are you going to get out of it and decide how do I measure that? If it's surgery, you know, hey, we just started this new procedure and we splash that everywhere. We put it up on the front page of our website. We let all the local clinicians know. I will tell you this, when I last ran a practice 25 or so years ago, we had a new modality that was financially efficacious. I looked at it. I ran the numbers. Worst-case scenario is primarily geared towards a certain population. So I looked at all our CPTs and DXs to find out, you know, do basically a sort of an if-then. If we get 20% of just this market, what's it gonna look like? If we get 40%, if we get 60%, what does that look like? Just try to build up conservative and then blow that up. And it was clinically efficacious. So it made all the sense of the world. And we were the only group in the area that was doing that. So what I had is I had the local paper come in and write a story on and I'm sure you could do that with local media and have them post it on Instagram. I follow, or their app, for instance. I follow a lot of local news organizations in the greater Atlanta area via their apps. And so, you know, have your lead doctor, the owner of that procedure, sit down and talk about it. What's so great about it? Why are you doing it? Who can be helped by it? You know, that kind of thing goes a long way. And oh, by the way, aside from the physician, their clinician's time, it's free press. So for me, what are we going to measure? The rudimentary graph is basically, here's what I spent. Here's how many patients I got from that ad cycle. My average cost was $74. Cost of acquisition, I paid $50 per person that I acquired via the radio. I mean, it's that level of detail, which also requires, again, on the front end or at the phones, someone needs to be able to capture. How did you hear about us? Why did you come in? That data needs to be measured, monitored, aggregated, and then the spend needs to be qualified. And then the revenue based on what you gleaned from that process. I hope that was clear to everybody. Again, a lot of moving parts, but it is a thing that requires implementation, execution, management. You think back to my ecosystem, you feed the beast, you manage it, measure, monitor, and then maybe your next spend or your next marketing plan, you learn from what you did, you grow and make some alterations, but that should always be dynamic, never static. Sectional procedure, cost and value based care. Can you give an example of a less expensive procedure that a family practice might want to evaluate? I don't know that I candidly understand that question. The value based care for me, and people throw this around all over the place, private equity guys and gals are into wanting to do value based care. The question is getting someone to define that so that you can measure it is a little bit all over the place. For me, it's delivering care that's quantifiable with quantifiable outcomes that you can measure and then you can then you can enhance and improve that care and you can hopefully lower the cost of delivering that care. The less expensive procedure that a family practice might want to evaluate, it just depends on what's in your portfolio right now. I don't know that it's a value based care proposition, but I'll tell you what my guy did and just farmed out to a local group is he did ultrasound in office and you don't even have to buy the machine. You can work out some plans that are legally above board and offer ultrasound or whatever the case may be there. And I'm sure a lot of you already do that. I'm preaching the fire. I don't know what a low, what an example of a less expensive procedure might be. I would contemplate, although you run afoul of probably the Derm folks, but there may be some Derm related product. I will tell you there is some in ophthalmology there historically has been some folks pushing multivitamins for arids, macular degeneration. So excuse me, dry eye. So that's up to you and it's up to your clinical judgment on what will deliver the best care. So I apologize. I think that's a non answer. But it really depends on what's in the portfolio right now. What you can add, that's not going to be a drain on the system and make people go insane, but will add value to the practice to your delivery of care and to the community. Section on security, the slide says network security is most important thing. I'm not sure if I said it's the most important, but it's pretty daggone important. I mean, if you think about all the areas that are open to not just corruption, but you read stories, probably read less lately, but about hackers getting into health systems and demanding Bitcoin ransom and things of that nature. When you have open exposure to the internet, which everyone needs, you're exposing your EMR and practice management system, all of the data, probably staff data. So that's all the social, all of that stuff. I would get a security audit that covers all of your IT components. And I would do it, I guess I would do it, not only the stuff that doesn't talk to the outside, but I think if someone infiltrates, and I'm not a 15 year old, you know, in my basement with a light bulb hanging over my head trying to figure out how to hack into Bitcoin. But I would think once someone gets inside, as long as those are interconnected, or intra, excuse me, interconnected, I would think they'd be able to bounce around and find stuff out and do some nefarious things. So I would look for a, an audit. And I do not do security audits, but I do know some folks that would do that. But that would help you have peace of mind and would help you avoid downside risk. Because you never know when someone on your staff is going to click an unsecure link. And then some Russian person is gonna, I mean, from Russia, I'm not trying to impute anybody, but some foreign actor is going to come in and hack your system. So. So again, these were the module summaries. Most of the questions I think, had to do tonight with really RevCycle. RevCycle part two, a little bit illegal, not as much an operation, a little bit of everything, I think. Many of these things, as I alluded to, early on, really are interrelated. So it's, you know, it's squeezing the balloon at one end, whether it's water or air, it's going to move elsewhere. And if it's one of those circus balloons, certainly, you know, it's going to go any which way. So I think it's crucial that people understand clearly how these things interact. And how a change in coding it will change revenue cycle, it could change revenue. If your physicians are on a, if your physicians are on a RVU model that changes, if you change CPT codes, the finance piece, we talked about credit line. You know, in a private practice, the profit and loss is the dollars in the door, what you have available. So if you have $100 that come in, and your costs are 100, there's $0 to give to the physicians, or the shareholders, excuse me. So if the shareholders make no money or collect, have no profit to be distributed to them, you may want to touch on your credit line, but you better make sure that's short term. And you're not six months later tapping into credit line, that means you have bigger, much bigger problems. So with that, I'll open the floor to anybody. And if there's nobody, that's fine, too. I'll give you back 10 minutes of your evening slash day. Great, great information. Great job answering the questions that had already come in. I do want to let everybody know that they also just to remind them, they're going to be getting a copy of your book, which will be also answering some of the questions and it does contain that great checklist at the end. So I think that'll make once they get that that may drum up some more questions. I appreciate that. One question that came in and I and I know this is another one that's kind of out there for you, Jeff, but it has to do with the charges that that a practice puts in place. Obviously, they want to go over their allowed the highest allowed amount for many of their contracts, correct. But, you know, you look at the bills that come from a hospital and their chart, you know, if a patient looks at those bills, they think, oh, my God, this physician is going to make bucks. And yet, in reality, they allowed amount is nowhere close to what the hospital is charging or what some practices. Yeah. Your experience, would you say to do that or should your charge amount be more reasonable over your allowed amounts, but not, you know, five times? Yeah. So it depends. Yeah, that's a that's a great question. I think in terms of the patient and their concern, and I will tell you, I had a child and I'm thankful I'm in the business because I understand what goes on. But I had a daughter and this is not a HIPAA violation because we've talked to other people about it. But she had a ACL tear four years as a division one athlete. No injuries ever. She decided to take up skiing. And on her third third venture skiing, she bled her ACL and then had an MCL tear. So when I talked to her surgeon, who is a surgeon for the Falcons and surgeon for I believe whatever our basketball team is here. Yeah, I don't keep up with pro hoops. But in any event, you know, my question to him is, I know how this goes. You have a surgery center. I'm going to get a facility bill. I'm going to get your bill. I'm going to probably get anesthesia and I'm going to get some sort of DME. So I know that and I know what to look for. And so her I will tell you her anesthesia bill for an hour was three thousand two hundred dollars, something like that. And I called them up and I said, I'm first of all, I'm not paying this because I know that the reasonable rate for anesthesia for an hour in your units is not going to be thirty two hundred bucks. Secondly, you haven't even billed my insurance company. I don't have an EOB. So when you do that, I'll be happy to pay you what the what the allowed amount is now relative to charges. It sort of depends on what your comfort level is, because there and I actually was going to throw this on a slide just for just for fun because I have a graphic kicking around. You know, there's an argument that some folks will want run one fee schedule and that way they just adjust off Medicare back to Medicare rates and they adjust off the commercial. Some people run a Medicare and then a commercial and they just bill Medicare at the Medicare allowable, which means they have to update that annually. I'm kind of of the one fee schedule things because charges never matter. You I'm going to say this and it's a little bit loaded. You never get what you charge. And if you do, that means you're under charging because you're you're getting the allowable, which means you didn't look at your fee schedules and you didn't negotiate in terms of we're talking about, say, a surgeon in private practice who is going into a facility or a surgery center. It may be worthwhile to flatten things out on a, you know, on a patient to physician basis or, you know, kind of that one on one interaction, like, hey, here's what you're going to see. You'll probably have an exorbitant bill from the hospital that's because hospitals charges are higher, whatever. You probably won't have to pay what that is. You know what I mean? Kind of level saying expectation in terms of your charges and you're saying, OK, the hospital is going to make 100 bucks off whatever we call Blue Cross Blue Shield, but they charge twenty five thousand dollars. You know, when the EOBs come around, the patient will see they don't owe twenty five thousand dollars. Now, if you're a clinician and you're in private practice and you know Blue Cross Blue Shield is going to pay you one hundred for a level three office visit, why would you charge ten grand? It makes no sense. Right. No one because because the old adage was, you know, when I was running cardiology, if we had one insurance company that would pay our calf at our at our bill rate because they want to get in the market and they're willing to pay the allowable at like three grand or four grand for a calf. I you know, when I get to the commercial payers and they're paying six, eight hundred bucks, I'm just writing the rest off. But but when you get into that situation, it's really, really exorbitant. You know, a lot of groups a bill, say three times of Medicare or something like that. You just have to decide what you're comfortable with. And I'm not telling anyone how to set their schedule. So you just you have to. I think it's a matter of comfort and then it's a matter of your market dynamic. And all these things come back to if you're in Valdosta, Georgia, in terms of the clinicians down there and the patients, probably a pretty small, intimate town relative to downtown Atlanta. So I hope that answered the question. If there's someone wants to reach out, that'd be great. I'm down with it. No, that was good. Excellent. And as you know, as Jeff mentioned, there it is. He's provided his cell phone number to reach him or you can contact Physician Services, send in any of your questions and we will make sure to get an answer for you. And we truly do hope that you enjoyed these modules. It's a wealth of information that we provided for you. We didn't just did that. He provided for you to team effort. Hope you enjoyed it. So thank you so much for your time. I appreciate it. Thank you. Take care.

medical practice management

revenue cycle management

insurance negotiations

patient billing procedures

financial management

practice management strategies

insurance regulations compliance

staff incentives

local market adaptation