16 years of practice management tips

[Doowai]

Background : I was a chiropractor 16 years prior to going back to medical school. My strategy was to buy a failing business, build it up and then sell it at a higher price to another chiropractor. I ran several offices, some of them vastly different than others. My first was an average sprain and strain chiropractic office. This was probably my largest success - just mainstream chiropractic My next was an acupuncture based clinic. I did one other that had a strong nutritional emphasis (this was probably my most profitable on an hourly basis). And my final office was medicare - acute get-me-out-of-pain senior citizens. Each required different marketing, billing, procedural etc strategies. All of them were fairly successful.

In my opinion, FP is not all that different than chiropractic in terms of running the office. I had mentioned my background, that I had kept my chiopractic background a secret (since many MD's do not care for them), but was willing to share my 16 years of office management experience. There was some interest shown for me to share some of the common themes of success I found in running practices. So I am creating this thread - if you find it useful, great.

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[Doowai]

HIRING STAFF: I was doing a rotation in pain management. My preceptor had lost a staff person and was hiring. He had someone coming in for an interview. He said to me "You have had your own practices for a long time, want to sit in while I interview this person and give me your opinion?" I said sure. Firing was not my favorite thing, although I got this down to a scripted format also, but I will share my opinion/tips on that later. But I LOVED hiring. I really found it fun. Plus it usually took me less than 4 hours total to interview 20-50 people and end up with my final choice. This was his second year in business for himself.

So I am sitting in his private office with him, when the lady who is interviewing is brought back for her interview. She was 50 or 60, wearing a t-shirt, sweat pants and fuzzy house slippers. She was very short (no problem there) but when she sat in the chair her feet did not reach the ground, and she constantly swung her feet back and forth like a kid. At one point the doctor asked her if making it to work every day would be a problem. She said no , she lived with her mother and could use her car....... unless her mother had to get her hair done or something, and then she would have to wait until her mom was done. She listed how much she liked doctors, listed quite a few significant health problems she had herself.

I listened, he stopped asking questions, asked me if I had any questions - and I said I did not (I had heard and seen everything I needed to). She left. he turned to me and said "what do you think?". At first I was shocked he would even ask. I said "Are you kidding?". He said no. I said "there is no way in hell I would hire her. Nobody you would ever want to hire would show up for a job interview looking like that, and you already know there will be days she won't be showing up for work." I also mentioned that I would bet money that she would be his #1 patient. She would wear him out by constantly getting his opinion etc about all her various health problems. he would end up so exhausted taking care of her , that his own practice would probably suffer. Her age, disabilities or health problems, sex etc cannot be reasons to NOT hire her as that is discrimination. However indicating she cannot make it to work when expected, and the fact she does not dress appropriately for the type of positioned interviewed for are sufficient reasons to exclude her. Please check with current state and federal hiring laws in order to be in compliance. In 16 years I never had a rejected applicant claim any discrimination.

He just wasted an entire lunch shift interviewing someone (one person) I would have eliminated as a possible choice in 5 minutes. I asked him how many people responded to his ad, how many people he had to interview and he said 20 or 30. In disbelief I asked , "are you planning on repeating that 20 or 30 times? Do you know how much your time is worth, and you are going to let someone like that just burn your time off?"

He then asked me how I would do it. I showed him. The next day I brought my hiring packet. It is roughly a 20 page stack of forms and information. He followed my directions to the letter, picked someone he clicked with in just a few hours of work - the only problem was he did not get his staff's input. My opinion does not matter as I would be gone in a month, but his staff would (hopefully) be there for a long time. The people you work with will be like family, you will spend so much time with them. I still get email from staff I had 6 years ago, and had a former staff and her husband visit from Texas who was a new-patient-assistant of mine 12 years ago. The people who I hired were and felt like family.

Step one - running the ad. I include something about it being a busy doctors office, and depending on the position the pay rate (more on that later), the hours, and what the job would entail. I also include that we will train and experience is not necessary. I mention it is a professional position and to dress appropriately. From this I typically get 40-60 calls in a large city like Phoenix and perhaps 20 calls in a small town of 3,000 (county of 6,000). I have the ad use my cell phone or home phone as the number to respond to - I do not answer the phone, I let them leave messages. This gives me a chance to hear how they conduct themselves on the phone.

Step 2 - the cattle call. I have my existing staff ask everyone if they could show up at 12:00 for an interview. If they say NO, I have my other staff tell them that is the only time we have open and they will have to check with me if there will another time. I DO NOT tell them everyone will be showing up at the same time - that is part of the test. If I am hiring for front desk I have my staff rate them on how they sound over the phone. If there is a major discrepency between my perception and their perception, I call them and talk to them for 30 seconds or so, and tell them I am excited to interview them - just so I can listen to them again.

I have my staff create a list of everyone who commits to coming. I also have them list of reasons why anyone could not come and their names.

On the date and time I find about 70% of the people show. I certainly grade them right away on appearance. This is a job interview in a doctors office - AC/DC shirts, fluffy house slippers show lack of professionalism. When it is time for the interview I lock the door. Often people come a bit late, the locked door lets them know right then and there that this is a major faux pas - if I hire them I want to reinforce from the beginning not to be late. I introduce myself, repeat what the add said (hours, pay, job responsibilities, etc). On v-e-r-y rare occassions I have had someone leave because they were not ready for a cattle call and could not/did not want to deal with that pressure.

I then pass out our the basic hiring packet (6 pages) - they fill in the basic name and address, references, job history, why they left their past job, what they liked about their last job, what they disliked about their last job, and has a brief questionairre rating themselves 1-10 on things like "are they a people person", etc. After they have worked on this for 15 minutes or so I interrupt them. SOme are close to completing the paperwork and some are not - I want to cover the cattle call questions with everyone all at once, but don't like waiting until everyone is done, as it makes some people wait way too long.

I then ask a few questions that may seem non-sensical, but to me they give me insight as to how the person would handle the position. For example, if I am hiring for billing/back office I always asked the question : "Imagine it is 4:30 on a Friday and you get off work at 5. Its been a very long week and you are sooooo ready to go home. I come in at that time and drop a huge pile of paper on your desk telling you 'I am so sorry. I somehow let this work slip by and it really is important and needs to get done today'. As you look at the work you find that one item is the city business license which has to be renewed by Tuesday of next week. You also find a Sports Illustrated subscription that needs renewing. You find a birthday card to my mom , as her birthday is next week and I want you to address it for me. You find a stack of workers compensation billing that is months overdue. What do you do?". I am looking for some type of answer that says they will prioritize it, do what is really important, but even though it means staying late they will stay late and do the real important stuff (billing and filling out the city business license renewal forms). I do not really grade off for the person who tells me they will stay as late as it takes and do ALL of it - but I prefer someone whose answer mentions prioritizing the work (Sports illustration at the bottom of the list and that my moms birthday card is not their responsibility-business license and billing at the top of the list). I have different questions for different office positions - front office, person who works with patients directly, back office billing.

I go around the room having everyone answer. It gives me a chance to get to know them better. I ask 3 or 4 questions, which lets everyone go near the front and everyone be near the last. I make notes on their answers.Step 2 takes about an hour. At this point I might have spent 2 hours of my time and have cut the deadwood considerably.

From these 20-50 I usually pick perhaps 10 to come back for step 3. The majority eliminate themselves for glaring reasons : really bad answers, real innapropriate appearance, etc.

Step 3 - skills testing. I invite perhaps 1/4 back for skills testing. My wife is smarter than I am, also very perceptive and I like getting her input so she does this section for me. I have several skills test : typing, 10 key, editing and grammer, math without a calculator, filing. Each section is timed and they rotate through the stations. Everyone shows up at the same time for this too. By the time the skills testing is done, they have spent about 2 hours in my office, and I still have only spent about 2 hours of my time. My wife and staff grade the skills test. Everyone in the office has to cross train in every job position, so if anyone is not present some day for whatever reason, everyone at least knows the basics of their job. From this I narrow it down to 1-3 people. If nobody seems wonderful, I may call back the people who could not make the first cattle call and schedule them for a second cattle call just so I can look over every possible applicant. I tell everyone that it may take me 2 weeks to make a decision, but we will be letting them know ASAP.

Step 4 - final interview with me. I have listened to my wifes input, listened to what my current staff thinks of them (this is HUGE, you DO NOT want any little wars going on in the office - your current staff needs to like them also), looked at their skills performance. I pick who I want, have them come in and offer them the position. I try to offer them the position the day immediately after the skills test and get them to start ASAP.

Step 5 - first week of work. The packet they fill out at the cattle call tells them they are on probation the first 30 days, and they sign that specifically. I believe I can tell in one week of work if most of them will work out. I DO NOT call any of those I have decided against, and tell them they were not chosen, until I am 100% sure this one is a keeper. If this one turns out to be flakey or something on day 4, I can always go back to my second choice and invite them in. If after one week everything seems good, and everyone else is happy with them , I have them call all the rejects and tell them they were great but they did not get the position, that it was a VERY hard choice as they were a very good candidate. No use burning bridges. Once I called someone months after I had hired, but the person I hired had to leave due to illness - and I ended up hiring someone I had interviewed all the way but rejected months previously.

Of course I had a training booklet for every position in the office : how to do everything step by step. This is why one McDonalds is like every other McDonalds and why they are successful. Every little detail is outlined and everyone is expected to pass a test on every section - they get a pay raise for each section they pass successfully with a perfect score. Every detail of the job is outlined . Ex. When answering the phone they are to 1) smile 2) let it ring twice 3) answer it with a specific greeting. There is no variation to this. I have them practice answering phones with each other, once with the other person smiling and once with them not smiling - and people can tell 99% of the time when the other person is smiling. It makes a difference, and the person answering the phone is your main connection to the world. Very early on, with my first business I had a real gloomy gus answering the phone, she was always depressed - my numbers dropped way off - people would call and this person who sounded like Ee-ore on Winny the Poo would answer with a real gloomy "Yeah?". It killed business. You want a cheerleader person handling the phones, or someone who is like someones VERY loving grandmother.

The grandmother type is great - patients love calling them : "oh child, whats wrong? oh that is awful. I am sure the doctor wants to see you right away. mmm mmm mmm. Oh my goodness. Lets get you right in".

Next to you (the doctor) the person answering the phones and dealing with people at the window is the most important person in building or killing your practice. Chiropractic and FP is built on repeat business. It is not surgery. You want these people to come back again and again - if the person greeting them is always gloomy or rude, your practice will never grow as well as it could - no matter how good of a doctor you are. And the patients might not tell you. You ought to call your practice once or twice and hear what sort of greeting you received.

Also in the training manual it tells staff to NEVER ask "Are you a new patient?". If someone has been coming to your office for 10 years, they feel as much a part of it as anyone - they feel they are part of your family. They expect their name to be instantly known - like an old friend. If a new employee asks this person, "are you a new patient?" - its kind of offensive, the long established patients feels like saying "Do you know who I am? I was Dr. So-and-so's first patient. I was coming here when their 3rd child was born, and I bought a savings bond for them". Front office or phone people , in my office, were expected to ask instead :and what is the nature of your visit?. If they were new either they would say they were new, or else when staff looked for their records they would soon see they were new. I know this sounds like a little thing - but little things is what makes one person first in the Olympic 100 meter sprint and one person second place. 1/100 of a second in the Olympics is the difference between being somebody and being forgotten.

I hate second place when it comes to business!

In my first few years I hired the most experienced. Huge mistake, in my opinion most of the time. Soon I found they were prima donnas - they felt they knew everything, were hard to teach new material to ("but in the old office we did it this way"..."well, if you like that office so much why don't you go back? In THIS office we do it this way"). The very best new-patient-assistant I ever hired was 18, just married, and never really had a job before. Whatever I showed her was the first time she had been shown that, she had nothing to confuse it with, and did it exactly how I wanted without trying to tell me (her boss) a better way to do it. I myself found hiring inexperience paid off - plus when they were promoted and making the money I was paying the "experienced" people from the outset, they felt they were making sooooooo much money. Someone who has made $20 an hour at other jobs just thinks that is standard. When someone who has been paid minimum wage at other jobs, and is of high intelligence and motivation but no experience gets paid $20 an hour they are flabbergasted. They will go to the ends of the earth almost for you. I had staff go over and above so many times. I had purchased paint and other things to redecorate the office, but went on vacation once - was going to paint when I got back. When I came back from vacation, my staff had completely painted and redecorated the office for me - and did not charge me a cent. Things like that happened with some regularity.

Now I understand in a FP practice you need to hire some training, someone needs phelobotomy skills etc. But I still find first-jobbers beat the person who has done it 10 years.

 

[HarveyCushing]

Hiring staff: I was doing a rotation in pain management. My preceptor had lost a staff person and was hiring. he had someone coming in for an interview. He said "You have had your own practices for a long time, want to sit in while I interview this person and give me your opinion?" I said sure. Firing was not my favorite thing, although I got this down to a scripted format also, but I will share my opinion/tips on that later.

So I am sitting in his private office with him, when the lady who is interviewing is brought back for her interview. She was 50 or 60, wearing a t-shirt, sweat pants and fuzzy house slippers. She was very short (no problem there) but when she sat in the chair her feet did not reach the ground, and she constantly swung her feet back and forth like a kid. At one point the doctor asked her if making it to work every day would be a problem. She said no , she lived with her mother and could use her car....... unless her mother had to get her hair done or something, and then she would have to wait until her mom was done.

I listened, he stopped asking questions, asked me if I had any questions - and I said I did not (I had heard and seen everything I needed to). She left. he turned to me and said "what do you think?". At first I was shocked he would even ask. I said "Are you kidding?". He said no. I said "there is no way in hell I would hire her. Nobody you would ever want to hire would show up for a job interview looking like that, and you already know there will be days she won't be showing up for work."

I am confused??? What's the point of the above post?

 

[Doowai]

harvey, a few days ago I mentioned my background and enquired if anyone wanted to hear practice tips I had gleaned after 16 years of running a health care office. People often enquire about practice management issues like "will this type of practice work"?. Several people said they would like to read the tips I would post and so I am going to create a thread, listing tips I have found useful on hiring, firing, billing, marketing, staff stealing from you, etc. hang in there - it might become clear as I finish the post. I have run successful offices in large cities like Phoenix and in very small towns (3,000). So some people might find useful tips no matter where they decide to practice. I would be happy if it saves doctors time and money making mistakes on issues common to every health care practice.

 

[Doowai]

Also in the training manual it tells new people to NEVER ask "Are you a new patient?". If someone has been coming to your office for 10 years, they feel as much a part of it as anyone - they feel they are part of your family. They expect their name to be instantly known - like an old friend. If someone new asks this person, "are you new" - its kind of offensive, the long established patients feels like saying "Do you know who I am? I was Dr. So-and-so's first patient. I was coming here when their 3rd child was born, and I bought a savings bond for them".

Reflecting back, at the end of my years in practice, when someone called in for an appointment, the definitive question to ask was : "when was the last time you were in?" If they were a new patient they would respond, "I have never been in before". If they were an established patient they would say, "Whenever".

 

[EdibleEgg]

Great thread! Keep going!

 

[MeowMix]

Very interesting. I'd like to hear you talk about how to handle med records and find staff who are detail-oriented enough to do a good job.

 

[futuredo32]

Great thread! Keep going!

I agree, this is an awesome thread(and I'm not even thinking about going into FP).

 

[HarveyCushing]

harvey, a few days ago I mentioned my background and enquired if anyone wanted to hear practice tips I had gleaned after 16 years of running a health care office. People often enquire about practice management issues like "will this type of practice work"?. Several people said they would like to read the tips I would post and so I am going to create a thread, listing tips I have found useful on hiring, firing, billing, marketing, staff stealing from you, etc. hang in there - it might become clear as I finish the post. I have run successful offices in large cities like Phoenix and in very small towns (3,000). So some people might find useful tips no matter where they decide to practice. I would be happy if it saves doctors time and money making mistakes on issues common to every health care practice.

Hey Doowai, sorry I must have got you in the middle of the post while you were going back to edit/add more. I just read the section I quoted and I was confused about it since I was even sure where it was going. Now it makes perfect sense, so thanks for sharing. I agree, continue adding what you have experienced.

 

[Doowai]

Very interesting. I'd like to hear you talk about how to handle med records and find staff who are detail-oriented enough to do a good job.

Okay, I will cover that. However my experience is you do not want detail oriented people for all the office positions. They are great in billing, terrible when working with patients or front desk - detailed oriented people in those positions bog down with details and things slow down too much. My experience was that different personalities fit different positions much better than others. For about a decade I had a practice management guru who had a degree in psychology and did a personality profile on everyone working in the office (including me) - detail oriented people can be very slow although thorough, not people you want in a position where you just want things to move fast.

 

[drwatson]

This thread is fantastic. I am looking forward to reading more about the setting up of the "nuts and bolts" for an office. Please keep this thread going. This type of material is invaluable for those of us considering opening their own practice and, yet, never gets mentioned in medical school

Thanks!

 

[Doowai]

This thread is fantastic. I am looking forward to reading more about the setting up of the "nuts and bolts" for an office. Please keep this thread going. This type of material is invaluable for those of us considering opening their own practice and, yet, never gets mentioned in medical school

Thanks!

I will keep this going. I have just been 1) sick as hell the past 3 weeks, very bad bronchitis and tonsillitis - lost 12 LBS. 2) depressed as hell about what residency will mean to me.

Today I plan on posting the informal questions I used during the cattle call for the main office positions of billing, front desk, patient assistant; and why I used the questions.

They did not cover it when I was in chiropractic school. I had been out of school a year when I saw a chiropractic magazine and on the cover was one of my classmates. Near graduation they announced the highest and lowest GPA's of our class without naming names - but we all knew who it was. We knew he had the lowest GPA. When they called the lowest GPA, he pumped his arms in the air like he had scored a touchdown and everyone cheered. He was anything but a scholar - but he was very popular. Everyone liked him. He was super social. Liked dating and girls alot. He was on the cover of the magazine because of a super successful business model he had - the guy made in his first month of business what many chiropractors make in their first year. I could not believe it. I spoke with a few of my other classmates and we were all shocked. But the point was hard learned, being super educated or super smart does not always translate into having a successful business. McDonalds is a fantastic business model, but its not based on having high quality food.

Many people with fantastic products (food or whatever) do not successfully negotiate the business waters. I am glad if this can be of help. Again today I plan on finishing the hiring information by sharing the informal questions I used at the cattle call depending on what office position I was hiring for.

 

[Rossdoc1978]

I will keep this going. I have just been 1) sick as hell the past 3 weeks, very bad bronchitis and tonsillitis - lost 12 LBS. 2) depressed as hell about what residency will mean to me.





Just going off topic for a second, what do you mean by that statement, do you regret doing an FP residency or did I misunderstand.

 

[nlax30]

Hope you feel better and looking forward to more from you! Definitely not something that gets covered much, if at all, in med school. Have met a couple of FP docs that do extremely well for themselves and both have said that, for them, it came down to becoming a smarter "business person" and changing things in their practice that weren't working well for them.

 

[Disciple]

Okay, I will cover that. However my experience is you do not want detail oriented people for all the office positions...

Would also be interested to hear your tips on effective marketing and marketing budgets, etc.

Thanks.

 

[Doowai]

I will keep this going. I have just been 1) sick as hell the past 3 weeks, very bad bronchitis and tonsillitis - lost 12 LBS. 2) depressed as hell about what residency will mean to me.





Just going off topic for a second, what do you mean by that statement, do you regret doing an FP residency or did I misunderstand.

It is off topic , but next year is my sons senior year. He and I are very close. Work out at the gym 4 days a week. We celebrate each others triumphs, and push each other. We have done an annual mothers day campout for the guys now every year for 13 years. I coached his basketball team and won the championship - he actually scored the basket that put us one point into the lead with less than 2 minutes on the clock. He is a state champion swimmer. He is finishing his second year of college calculus. I know his first kiss, and all sorts of secrets. Saturday for earth hour he and the rest of my family laid outside looking at the stars under a blanket just talking junk. He says he is willing to move for my residency, but I cannot move him his senior year after going to the same school K-11. I feel such sorrow that I will not be here for his senior year, nor that we will get to see each other daily. Residency to me means not seeing my son or my other children on a daily basis next year.

 

[Doowai]

Would also be interested to hear your tips on effective marketing and marketing budgets, etc.

Thanks.

Marketing was one of my most favorite things to do. I loved hiring, marketing, lunch time, and going to the bank.

 

[Doowai]

HIRING NEW STAFF : Final chapter

CATTLE CALL QUESTIONS FOR FRONT DESK:

1) You are working as an apartment complex manager. There has always been a NO DOGS rule. The apartment owners have been lax about this and many tenants have dogs. A new owner buys the apartment but wants to strictly enforce the rule. You notify everyone and everyone complies ...... except for one little old lady. She has a tiny dog and has not gotten rid of it. What do you do?

I am looking for a response that indicates a ton of empathy and sympathy, someone who hates to make the old lady comply, but who knows they are an employee and do not make the rules, and that it is not fair to everyone else who went ahead and got rid of their pets. I have heard all sorts of answers : some people who would take the pet themselves. Some who would help find a home nearby so the old lady could visit the pet. Others who would just let her keep it and cover it up so the new owners did not find out. Others who would tell them old lady to get rid of the pet or they are throwing her out.

I want someone very warm at the front desk. Someone very sympathetic but who can follow rules. I want this because I want someone very warm and friendly at the front desk, very understanding, but at the same time takes patients to task about keeping their appointments. I want the front desk person to know there is a reason for the appointment (proof of cure, diabetes check, well baby exam) and while being very sympathetic and caring making sure patients keep their appointments.


2) The waiting room is packed with patients. All of a sudden another patient enters. They got a bill for something they were sure their insurance should have paid for. They explode in anger at the front window. What do you do?

In 16 years I have had this happen perhaps 5 or 6 times. My collections were laways greater than 92%, and small claims court of collection agencies were just not my thing. I will discuss how I try to have good billing and happy customers - which I think is a very possible reality.

I am looking for one response as a minimum - they are wise enough to know to remove this person from the waiting room to a private room to discuss this, so the venom does not spill all over the other patients. Other things I teach my staff, and would hope people know is : 1) listen listen listen. Do not argue with them or even discuss it with them until they have said all they want to say. They are emotional and they are in the mood to vent, if they do not do it here they WILL do it at home to their friends - who could be patients of yours now or be possible future patients. Let them vent until they seem to run out of steam. Then encourage them to talk some more : Is there anything else? Do not take it personally. They are not mad at you. Once they have truly said everything they are going to say, then repeat it back briefly to make sure they know they have been heard. Then assure them you will make sure its taken care of, not right now but within 24 hours. If necessary you will get the doctor (you) to review it - but all of this listening and discussing etc was to be passed off too, and taken care of by our back office billing assistant. Let them know that we make no gaurantees to get insurance to pay, or that we accept only what insurance pays - insurance helps with the payment and ultimately it is the patients responsibility. But assure them you have heard them, understand they are upset, and will take care of this ASAP - within 24 hours if at all possible.

3) What gratification/satisfaction do you receive from working in such an environment?

There is no specific answer I am looking for. You will find answers that please you and some that don't.

When applicants are giving me their answers I have a list of their names or where they are sitting, and make notes of these answers to review later when I am deciding who to invite back for skills testing and later for the final selection.

 

[Doowai]

CATTLE CALL QUESTIONS FOR NEW PATIENT ASSISTANT

1) You are working as a secretary at a law firm. You have worked there a long time and know quite a bit about how things are done by the attorneys and why. An anxious client approaches you with a legal question. The question is simple - you know the answer. The client is a personal friend. How would you handle the situation?

I am looking for an answer something like this : " (friend), you should know better than to put me in such a position. I am not an attorney and I would not want to jeopardize my job, or our friendship by giving you information I am not licensed to give. I am sure Mr.Lawyer can help you very soon". No matter how long patient-care staff is with you, they are not a doctor and should never assume any of the responsibilities that are your alone, or that of the PA or NP that is working for you.

2) Describe your greatest asset.

The response may range from one statement to long monlogues. There is no one correct answer. It gives you a chance to access the potential employee and make a final decision.

3) You are making special cookies for your child' school bake sale. The recipe is complex. The recipe is very precise and step by step. You are not a highly skilled cook. Some of the things it asks you to do seem kind of superfluous and silly. You are missing one of the exact ingredients but it seems that you could substitute something you do have for it, but you wonder if you should. What do you do in this situation?

I am looking for someone at this point who will follow directions perfectly. My front desk people I want to be quick - get them in - and get them in quick, check them out and reschedule them quick, make things move. My billing and new patient assistants I want to do things precisely - mistakes can cost you in big ways. I am looking for someone who if they need help will ask for and find help, but they plan to do it by the rules, by the recipe.

 

[Doowai]

CATTLE CALL QUESTIONS FOR BILLING/BACK OFFICE ASSISTANT:

1) See cookie bake sale question.

2) See my above example about giving them a stack of work to do at 4:30 on a friday. I am looking for someone who prioritizes this sort of thing. Whether they stay and finish all of it (I have had some who said they would even write a personal poem for my mothers birthday card) or just simply finish the most important tasks - I want someone who prioritizes and does the most important things first.

3) What sort of gratification do you receive in billing and collecting from cumbersome bureaucratic agencies and patients who say they will not pay or do not have money to pay?

I am looking for some sort of answer that has to do with making sure systems are operational. Enjoying doing what others find difficult. Enjoying making sure people do the right thing, which inculdes paying for things they receive (otherwise its stealing - taking something including services without paying is stealing).

You need to know they are comfortable with taking money. I had a staff person that was a great back office person. However I started them as front desk. One of the front desks jobs was collecting money. She was very poor and from a very poor background. She knew what it was like to be hounded by creditors. Her mindset was : there is not enough money in the world, and its wrong for people to squeeze money from good people. She killed my collections until I moved her. When she asked for money from patients there was guilt in her voice. SHe felt wrong asking people for money. When she asked for money, no matter what words she used it sounded like she was saying "Is it okay for you to give us some money.... its not okay is it...I am sorry.... we should not ask you for money?" People started questioning my bill.

You have to have someone, wherever you ask for money, who 100% entirely feels your fees are fair, that you do honest work, and that it is only right for you to get paid. They need to know that you getting paid means you continue to provide service to lots of people, and that you getting paid means they get paid. They need to know that you work hard for the fees you charge.

 

[Doowai]

I can give information on preventing discrimination during interviews (race , religion etc) - is anyone interested in that?

 

[Doowai]

Remember this : if you work for yourself, one of your main goals is most likely to have more money and more free time. Your time is the most important thing. If you lose all your money you can get it back - quite possibly the very paper you lost. If you lose one minute you can never get it back.

Ideally you will retire in practice. In this day and age, many of us will never store away 10-20 million dollars and simply sit back and do nothing and be fully retired. However it is possible to retire in practice. That is what my ideas are all about. Do what you do more quickly and more profitably, without sacrificing integrity. This last part has been about how to hire the best person with as little time spent on your part - not because you are lazy, but because you have so many other important things to do (at work, at home, in your civic community - doctors should be civic leaders in my opinion). There is really no need to spend 20 hours to interview 20 people. Likewise many of the things that are done can be done much more efficiently with some organization and some systemization (higher life form).

When I lived in a town of 3000, a farmer once told me that whether you had 10 acres or 100 acres, you could spend all day working on it. He told me you had to learn to "get r' done".

Everyone likes sex, but few people like it for 100 hours a week. Everyone here probably likes, maybe loves, medicine - but 100 hours a week for 30 years can destroy you.

The point is to get it done, not waste time, and have some balance in your life.

HIPAA laws are pretty standard. I was still in practice when HIPAA laws came out. But there is alot of information on this. I would rather not spend much time on this. Its kind of like spending alot of time on correct coding - once you learn the basics of CPT and ICD its not that hard, you can create forms with bullets that allow you to meet all the requirements of various levels of service. You can also learn pretty easily which diagnosis' will get you paid. I know few practice management companies for MD's - and many focus on mundane things like coding. Its really something you can learn on your own with little difficulty.

Things I would like to address includes how to schedule your practice hours, training people, firing people, managing patients who love to suck up your time but don't really need it, marketing with little headaches (both internal and external marketing), practice pitfalls, dealing with declining insurance, collecting cash or increasing the cash portion of your practice, gaining specific types of new patients and a few other things.

Its not too bad to work 30 years at something when you feel retired in practice - you are not working too many hours, you get plenty of vacations, feel rested most of the time, and are not spending alot of time putting out fires.

I went to medical school out of boredom - I had it too easy as a chiropractor. I also felt I was not doing enough for the money I was making - I was not doing anything illegal (billing for services not performed etc), but I felt I should do more. Chiropractic spinal manipulation is a beneficial service - it relieves many peoples pain quickly at a low cost, but I felt like it was not enough to be doing. Now I am thinking I am crazy. I had several medical preceptors ask me that, "are you crazy?". Now I see what they mean. Right now I would love to be once again working 20-30 hours a week, making good money, having good vacations and the money to do something on that vacation.

But in a few years I should be able to replicate what I did as a chiropractor, but in a bigger broader more beneficial way. Joint injections, etc would make chiropractic work much more effectively. Medicine is a much more powerful tool. But chiropractors have a good practice paradigm. Most are retired in practice - working part time and making good money. They cannot bill Medicare for x-rays , exams, therapies etc - but still make good income, despite poor insurance reimbursement.

 

[mikereno1]

Doowai, this is very very helpful. it is nice to see that there are great business models out there for making a successful private practice. We dont get any exposure to the business aspects of practice in medical school itself, and i have heard not enough exposure during residency. Great post, the more the better

 

[Doowai]

RE: Starting a practice, please at least consider the lecture thing as a main form of marketing. Its best if you learn to do public speaking - but note having experts in your office to speak on topics other than medical health care. People love these and certain topics are real buttons - like DEALING WITH YOUR TROUBLED TEENS , or investing tips.

http://forums.studentdoctor.net/showthread.php?p=6473934#post6473934

 

[Doowai]

If you become an employee, you will probably get a salary and a bonus system based on production.

I would work into your contract that your bonus system is figured differently for patients YOU bring into the practice and those that just come into the practice. Lets say you get hired by a group that has been in practice 7 years - some new patients are going to come into the practice from referrals of patients who have been coming there for years, or because they have seen the clinic before. But if you do lectures or other self promotion - those patients came in because of YOUR efforts. So you ought to get more credit for those patients.

Ex. if your contract gives you a base salary of $10,000 a month and , I don't know - I am just making this up - 3% of any collections over 30,000 a month.... you ought to get perhaps 6% for collections that are tied to patients YOU brought into the office - because the group would not have had that patient if YOU were not there. If the patient comes in because of the offices inertia than you get bonused at the lower level, if they come in to see YOU because of your own efforts and marketing, you ought to be bonused at a higher rate. Then you can have greater control over your salary - you still have an incentive to market your practice (which is good to the group if YOU are trying to build it, instead of just letting inertia drive the new patients) - and lectures (even if done by others) are a GREAT marketing tool. It gives you a sense of ownership in the practice. Plus your contract should state , any patients you brought into the practice can follow you to a new practice and it is not a non-competition violation.

 

[deleted87716]

I would work into your contract that your bonus system is figured differently for patients YOU bring into the practice and those that just come into the practice...Plus your contract should state , any patients you brought into the practice can follow you to a new practice and it is not a non-competition violation.

IMO, both of these are unworkable. Tracking charges for "patients you brought into the practice" will likely prove to be well nigh impossible, and you'll be forever questioning whether or not you're getting the money you think should be coming to you. Not a good recipe for cordial relations with your partners/employers. You'd be better off simply negotiating a fair production bonus and be done with it.

Most non-competes are geographic, prohibiting you from practicing "x" specialty in a "y"-mile radius of your old practice for "z" years. They have to be reasonable (something like 25 miles for 2 years is typical). A practice can't prevent patients from leaving, whether they choose to follow you or go elsewhere, so don't expect to see anything like that in a contract. Non-competes are almost always going to be part of your contract, so get used to it. The stronger the group, the more likely they are to have a non-compete. Non-competes are enforcible, and should be taken seriously. Any group that has a non-compete is actually obligated to enforce it, otherwise they set a precedent which essentially nullifies the non-compete in the future.

 

[Doowai]

IMO, both of these are unworkable. Tracking charges for "patients you brought into the practice" will likely prove to be well nigh impossible, and you'll be forever questioning whether or not you're getting the money you think should be coming to you. Not a good recipe for cordial relations with your partners/employers. You'd be better off simply negotiating a fair production bonus and be done with it.

Most non-competes are geographic, prohibiting you from practicing "x" specialty in a "y"-mile radius of your old practice for "z" years. They have to be reasonable (something like 25 miles for 2 years is typical). A practice can't prevent patients from leaving, whether they choose to follow you or go elsewhere, so don't expect to see anything like that in a contract. Non-competes are almost always going to be part of your contract, so get used to it. The stronger the group, the more likely they are to have a non-compete. Non-competes are enforcible, and should be taken seriously. Any group that has a non-compete is actually obligated to enforce it, otherwise they set a precedent which essentially nullifies the non-compete in the future.

Tracking patients you brought into the practice is not impossible, but I would have to agree that it can create less than cordial relationships. But then again, bottom line for me is (after care and concern for the patient is done) its business. But my opinion on the value of cordial employment are changing. 10 years ago I would have never considered being an employee on salary - I saw salary as 2 people trying to take advantage of each other : the employee trying to work as little as possible for the salary and the boss trying to get as much work out of an employee for the salary. However my viewpoints have changed a bit - and a cordial work environment is important if you plan on being a long term employee.

Non-compete clauses can be worked many ways, depending on your skills at negotiating. Negotiating is uncomfortable for many people - many even dislike dealing with car salesman because of it. Negotiating can be fun : learning different negotiating styles, the fun of changing a NO into a YES. Depending on your comfort with negotating, a contract can say all sorts of things. You are right about what is standard in a contract - X distance for X time (distance is usually greater in a rural area since the patient base is wider, and smaller in the city since the patient drawing distance is usually smaller).

 

[Doowai]

http://forums.studentdoctor.net/showthread.php?t=511198

I added some information on billing and understanding Medicare insurances.

 

[Doowai]

http://forums.studentdoctor.net/showthread.php?t=511831

The Dr.Patmos that a link is posted to has some good ideas. His ideas are kind of what I have tried to convey - he is basically retired in practice. Working 8-1 Monday through Friday, and 9-1 on Saturday. SOme good ideas to read. He recommends having only one staff person to do clerical work and front desk work (since his is an insurance free practice). I myself think that a better schedule for patients would be 8-1 M-W-F, and 2-7 T-TH. That way you can take care of people who want to get in early and those that need to get in late after work.

However at the very bottom of his menu is a button titled "Backwoods justice" in which he describes a secretary who embezzled $60,000 from him. I had something similar happen once. When he found out she went kookoo and stole from him he probably fired her right away. But then he is left without a trained person at the front desk - not so big a deal when you don't bill insurance, or don't need a nurse like him.

First, one thing I disagree with is having one person you depend on like that. I always like to have 2 people. I had a clinic I transitioned to a very part time slow clinic when I was trying to go back to medical school. I worked 3 days per week, 8-11 and 3-6. I often worked slightly less. Instead of having one person work the front desk all those hours, I had 2 people : one work mornings and one work afternoons. That way if someone goes kookoo, you can fire them and simply ask the other person to fill in a bit while you hire someone new. That office I did bill insurance (I had to bill medicare, chiropractors cannot opt out like MDs and DOs) - and I had a 3rd person who came in once a week and pushed a button to bill electronically. But instead of one "full time" person I had 2 people work the 2 different shifts - that way I always had back up.

I do agree with him you can run an office like that with just you and a front desk person. If you are not afraid to do a bit of "scut" work. When you hire another staff person you have to see more patients to cover their salary - but when you see more patients your costs go up due to more supplies needed etc - and it can spiral. You want to strike a happy balance where you can take care of your sick clients, make good money, and have enough free time that you kind of feel retired.

If our economic environment stays roughly the same you should be able to work 30 hours per week or less and make a positive cash flow of $100-200,000 a year (discretionary spending after fixed business expenses). Chiropractors do it all the time and they do not have the pulling, billing , service power of an MD ( with chiropractors I am referring to positive cash flow and not necessarily taxable income : http://forums.studentdoctor.net/showthread.php?t=511198 see post number 13). But they are a saavy community.

 

[Doowai]

Staff that embezzles : I had a similar situation once. Dr.Patmos should have seen this coming. He is at the highest risk for embezzlement for 2 reasons : 1) an all cash practice. Sure many people are paying with checks, or credit cards, but many are paying with plain old greenbacks. Easy to pocket. 2) Second he had only one staff person - nobody was watching the person watching the money.

I had this happen once (shame on me). Its a simple thing. All of my clinics had a fair amount of cash, for 2 years I was all cash. Every patient coming in gets page one of a 2 part superbill (receipt). The superbill lists all the services, fees, any payments made and the next visit. It also lists your employer ID number, insurance identification numbers, state license, and their diagnosis so they can bill their own insurance.

So a patient finishes their visit and goes to the front desk. For this example they pay with a $20 bill. The front desk marks their payment on the superbill, tears it off and gives it to them. Then instead of filing it, they throw it away, and fill out another superbill but mark zero payment. On the patients ledger card they mark the payment so that the patient is never sent a collection notice. They then put the superbill copy showing no payment in the days receipts - to you it looks like they did not pay the $20 , but your staff is $20 richer.

$40 a day, is $200 a week, is $800 a month, is $9600 a year. Not big enough to notice if you are doing 2 grand a day.

What to do is simple : all superbills should be consecutively numbered in the upper right corner with red numbers. All staff is instructed YOU NEVER THROW A SUPERBILL AWAY. Even if you make a mistake , just put the messed up superbill in the days receipts, and fill out a new one correctly. YOU NEVER GET OUT OF NUMERICAL ORDER.

At the end of the day you go through the receipts, making sure there is a receipt for every patient you saw, that it is in numerical order with none missing. Compare it to the days ledger sheet, and see that the numbers coincide.

It is important that all patients be told that all payments should be marked on the superbill That should be written on the superbill as well. Tell them something like, if they fail to get a receipt for a payment, their next visit is 10% off or something like that - so that they have an incentive to report to you any time the front desk takes a payment but fails to put it on the superbill.

Staff can get very clever. I knew one guy whose secretary was actually forging signatures on checks from insurance and depositing them in her account. if alot of money is passing over your desk, they will be very tempted.

 

[Doowai]

If you have a good accountant, much of the basics of running a business legally will take care of themselves - getting a tax ID number, making sure you have an up to date business license, making sure you are compliant with state and city taxes. And these mistakes are somewhat forgiving - I once looked at the wall and noticed my city business license was something like 8 months expired. I called the city, I made up the amount in error - which was not much, and got a new business license. No big deal. Some of the links KentW kindly provided have some great details on covering all these bases step by step.

The most unforgiving thing I have found, in my experience, to business success is having a mindset of poverty, or of lack.

WHen I was doing my general surgery rotation, a patient came in. SHe had been undergoing therapy for breast cancer. The surgery had been done and she was now doing brachytherapy. The surgeon was kind of overseeing the whole thing. The patient was near the end of care. Her insurances had changed and she now had a $70 co-pay each time she saw this doctor. Not many visits left. SHe told the doctor, "I am sorry I cannot come back - I have a $70 co-pay because you are not on my preferred provider list, so I am going to switch doctors."

Without saying anything else the doctor said, Okay I understand. I was flabbergasted.

In similar vein I cannot count how many times I saw a patient with a primary care physician - we would leave the room and they would say something like, I think such-and-such medication or such-and-such therapy would be best for them. Then the doctor would look at their chart, see their insurance and go : Oh darn, their insurance does not pay for that...well lets see, I will prescribe such-and-such-number-2 for them since their insurance covers it. Again I was flabbergasted.

In both cases, the doctors did not really concern themselves with what was best for the patient - switch doctors near the end of treating a serious illness, or get the best drug or treatment available - it was just lets go cheap.

When the cancer patient left the surgeons office I remember exactly what I said : Dang, you are treating her CANCER and she dropped you over $70 bucks. Last visit she mentioned how she was paying her dentist to whiten her teeth. Thats like $1000, and its all cash. Her white teeth are more important to her than her cancer treatment.

The surgeon looked crestfallen. SHe mumbled, Wow, you are right. I then told her my revelation on that.

In August 1993 I was in a small (pop.3000) Missouri farming town. People often drove up in beat up pick up trucks, and had hunting dogs in the back - wearing dirty overalls and with cow manure on their shoes. I was not doing well financially. I bought the office from a sick chiropractor who was retiring for $10,000 in March 1991. I owed nothing on it when I bought it, I pad cash. I had $2000 in the bank after doing that. I had just moved to the town from Phoenix, with my wife of 15 months and my 2 week old son. I made a profit from day one, and a cleared about $40,000 positive cash flow after business expenses in my 8-9 months of ownership in 1991. But I knew I was not doing well. I hired a practice consultant from Glendale Arizona. We were on the phone and he was asking me about my business - I was complaining about these poor farmers who had no money. I would see them get out of there pick trucks, know they were poor, knew they could not understand technical explanations, and could not afford any care - no rehab exercises, etc,

The consultant asked me to describe my patients and I described them ironically just as above. He looked on a map and said "Aren't you close to the Arkansas border?". I said yes, about 20 minutes from it.

He asked me if I had ever seen Sam Walton. I had seen him once when they opened a Walmart at Biscayne Mall in Columbia Missouri. I was with an old friend of mine named Mark, and as we came out of the new Walmart this old guy said "See that store, I own it. Its completely paid for". My new consultant asked me, what did he look like. In stammered, he was driving a beat up pick up and he had a hound dog in the back. My consultant , who had set me up, said - how do you know the scruffy farmers coming in are not just like Sam Walton.

He told me, you are assuming. Assuming they can't pay, assuming they can't or won't keep visits etc. Forget about your preconcieved notions and simply look them in the eye and simply tell them what you really think and recommend. Let them decide what is too expensive or time consuming, and that I might be surprised.

I did this, and my business grew 500% by January 1994. And my reputation grew - people got better results. They talked about what a great doctor (okay okay, I know in this forum I was not considered a chiropractor) I was, and how much better they felt (of course, now many of them were doing good rehab etc). Plus I was making alot more money.

 

[Doowai]

You would be surprised the money some people have. I needed a new washer and dryer in that small Missouri town. A friend told me about a guy who had a bunch. The guy would get broken ones , fix them and sell them. My friend drove me out to the guys place - he lived on an isolated stretch of road and looked like a character out of the movie DELIVERANCE. He had 20 or 30 machines sitting in a barn. He was selling machines for like $25 or $30 a piece. I had brought a hundred dollar bill and wondered out loud to my local friend if a hillbilly like this would have change.

My local friend said; this guy will have alot of money on him, don't you worry.

I bought the machines and handed him my friend Franklin, and he pulled a wad of cash out of his pocket that was the biggest I had ever seen by that time. Now that I have seen several such stacks of cash, I am sure it was between 3-5,000 dollars.

I have been teaching at a public school now for almost 2 years. I have been at a very poor ghetto inner city school with heavy gang affiliation. Last month funds for non-certified teachers ran out for that school and I got switched to a school in a brand new subdivision, that is MUCH wealthier.

My second week there I ran into a student who had gone to the previous ghetto school. I asked them why they moved - someone had broken into their house and her parents felt nervous about her wellbeing. So they just bought a new house in the subdivision, without even selling their old house yet. Many people in the old ghetto school neighborhood have been there 20 years or more. Their houses, while not rich or fancy are sometimes (often) paid off. They have low to no debt. Much higher cash flow.

In contrast when I moved back to the Phoenix area in 1998, my first chiropractic office was on the corner of Scottsdale and Shea in Scottsdale Arizona. Very expensive area. Lots of Barbie Doll wives driving Lexus as a bum-around-car. Very expensive homes. And people are mortgaged to the hilt - almost no expendable cash since all their money is going to car payments, private school payments, huge house mortgages, and plastic surgery.

The people in the ghetto surprisingly often have much more disposable income. Never assume.

 

[Doowai]

If patients come in and you think they need X drug, but it is not covered by their insurance have enough concern for them, to at least offer them the best : Mrs.Jones, you have such and such a condition. I think X drug is the best. Your insurance only covers Y drug, which in this case I don't think is as good. What would you prefer?

Let them decide.

Mr.Jones, your blood sugar is running high. Your insurance only pays for an office visit every 6 weeks , I would like to see you every 3 just to see if you are being compliant, checking your blood sugar as you should, keeping your blood pressure in check - I just don't trust home machines that much etc. It will cost you $60 for that check up. I think it would be much better for you, I think you are the type of person who is more likely to be complaint if they are having to be accountable to someone more regularly. I just think you tend to get lax when we go every 6 weeks (or longer). Insurance won't cover the more frequent visits but I really think you need them. What do you want to do?

People buy refrigerators that cost $2000. They do not use insurance to do it typically. They do not walk into home depot and say they want a refrigerator, but they do not feel they should have to pay for this one since they are such good repeat customers - you know we have bought a stove here, and bought linoleum here, and bought some plumbing supplies here - so they feel they ought to get the refrigerator for free. People buy TV's, refrigerators, cars, and tooth whitening and pay cash for it. They buy $25 of pizzas on Friday. They spend $100 for tickets to a 2 hour basketball game. They spend $40 to see a 2 hour movie. And you want me to believe they cannot pay $70 for CANCER TREATMENT?

When you are $250,000 in debt as a student, you may feel nobody has money because you don't have money. We tend to generalize to the world around us. We often project ourselves onto the world. We often assume based on expectations - how they are dressed, how they talk. Somone you look down on may be able to buy and sell you 5 times over.

Always look the patient in the eye and suggest to them what you feel is the best, never what insurance covers. Give them the opportunity for the best care. Let them decide what is right for them - if they want to spend the extra money let them.

 

[Doowai]

You forgot the obvious:

Perform fake procedures to maximize reimbursements.

I suppose that is an insult on chiropractic. In the midst of your insults don't miss out on anything useful that I share.

In my years as a Chiropractor I never billed for something I did not actually do, nor for something I did not believe in. I never sent a bill to insurance that I would not expect a patient to be able to pay (like billing $25 for a pill given in the hospital that would cost a patient 50 cents if they bought it on their own outside the hospital) just to pad the bill. To me gouging insurance like that is really not ethical. My fees were always reasonable, my collections were always above 93% - because if insurance did not pay I expected the patient to. I never trumped up the number of visits, or charged something like $600 for a cervical collar (as I have seen done in medicine) that might have cost $25.

My wife was hospitalized for 3 days in 1990. Insurance declined it , because they labeled it as a pre-existing condition. It left us with the entire bill. I paid it off even though it took years. But I got an itemized statement, and the hospital dropped alot of the fees - something like $50 for a little plastic water pitcher they say they gave us, A similar charge for a box of tissue they say was in her room that they say they gave to us when they discharged her. I mean seriously, $25 for a box of tissue? In all honesty I have to say the worst chiropractic offenders that I have seen (and I have seen a few I think are borderline criminal) have never gouged like that - I mean it really is essentially stealing, it is much like charging usury. So you can hop off your high horse and worry about making your own profession better.

There is some research indicating spinal manipulation, certain therapies, acupuncture, and rehabilitation exercises have some merit in helping musculoskeletal conditions heal quicker and with better long term results. You may not believe it but there are several studies - I am not going to digress into that there.

However putting your attempts to bait me aside, try and see if there is useful information here.

And hopefully you never have billed for an office visit to prescribe Vytorin or Zetia - because they do not work, in which case you basically billed for sham therapy. Due to their harsh side effects, it would have been better if you had prescribed chiropractic for their heart disease than those drugs - maybe slightly more effective and certainly much safer. Learning how best to treat sick and injured people is a work in progress - medicine and chiropractic have made progress in the past 30 years.

 

[Doowai]

The next visit :

 

[deleted87716]

And hopefully you never have billed for an office visit to prescribe Vytorin or Zetia - because they do not work, in which case you basically billed for sham therapy.

Whoa, whoa, whoa. I'm not trying to derail your thread, but I've had just about enough Vytorin/Zetia conversations in the past few weeks to last a lifetime. The ENHANCE trial is too complex to be understood in media sound bites.

ENHANCE showed Vytorin is more effective than simvastatin alone at lowering LDL, triglycerides, and hs-CRP, and equally effective as simvastatin alone at reducing CIMT, a surrogate marker for cardiovascular disease. The effect of this on clinical endpoints such as heart attack and stroke has yet to be determined. The study design of ENHANCE is controversial, and I think it's important not to let hype cloud sound medical judgment. Vytorin and Zetia remain perfectly viable options for patients who cannot tolerate higher doses of statins. That's the way I've been using them in my practice since the very beginning, and ENHANCE does little to change that.

Carry on.

 

[Doowai]

Whoa, whoa, whoa. I'm not trying to derail your thread, but I've had just about enough Vytorin/Zetia conversations in the past few weeks to last a lifetime. The ENHANCE trial is too complex to be understood in media sound bites.

ENHANCE showed Vytorin is more effective than simvastatin alone at lowering LDL, triglycerides, and hs-CRP, and equally effective as simvastatin alone at reducing CIMT, a surrogate marker for cardiovascular disease. The effect of this on clinical endpoints such as heart attack and stroke has yet to be determined. The study design of ENHANCE is controversial, and I think it's important not to let hype cloud sound medical judgment. Vytorin and Zetia remain perfectly viable options for patients who cannot tolerate higher doses of statins. That's the way I've been using them in my practice since the very beginning, and ENHANCE does little to change that.

Carry on.

LOL...okay then change that to alcohol IV's as a tocolytic and prescribing cigarettes for asthma.

 

[Doowai]

First visit (new patient):

 

[deleted87716]

LOL...okay then change that to alcohol IV's as a tocolytic and prescribing cigarettes for asthma.

That's more like it.

 

[Doowai]

Establishing your office schedule:

If you are not careful you could go from residency with call Q3 (1:3) to being in practice for your self and having call Q1 (1:1). You need to set up some hours. Word of warning - be wary of patients who violate your established posted hours, they are going to be pains in many other ways.

Now keep in mind I have had 16 years of chiropractic practice, I have not practiced as an MD yet - and even though I have done thousands of hours of medical student rotations, there may be some practice dynamics I am not aware to family medicine that may alter this some. But I will give you my years of experience, from having several practices with drastically different demographics.

The first thing you need to do is establish your PTW (Prime time wave), it is the hour or two that is your busiest. It is when it seems everyone wants to get in to see you. Medicare based practices tend to be anywhere from the time you open until about 9 AM. Younger Families tend to be 5-7 in the evening when they get off work.

Your PTW should be devoted to one thing only, seeing those patients, moving them through. It is the hour or two you move fast (but not too fast as to risk negligence). No new patients, or patients known to eat up time with things like telling you golf stories etc, and NOBODY on staff is to do anything other than process patients coming in and out right then. No billing, no reviewing other patients bloodwork, no calling patients with lab results etc. Just take care of the business at hand.

PTW is the popular time for your practice, and you need to accomodate as many people as possible.

After you have established your PTW, you will schedule 2 other times : up time and down time. Down time is the time you are not going to have to deal with any patients in the office. Down time is when you are not dealing with real-time people - you can call regarding consults, review bloodwork and sign off, deal with insurance hassles - all staff is dealing with non-real-time patient concerns. A dedicated half-hour to two hours of this daily will really keep work from piling up on your desk. Not having specific unviolated downtime, trying to squeeze these concerns in while seeing patients will leave you rushed with your patients in office, and will leave paperwork piled up on your desk. Organize your time - organization is a higher life form - it will give your practice a higher life than winging it and putting out fires all day long.

Up time is time you are dealing with new patients, slower patients, but you can do interactions with patients not in the office : call and deliver results, call and see how patients are doing, and other activities when you are dealing directly with patients who are not in your office right at that time (you are still dealing with patients, but indirectly such as over the phone).

My consultant (circa August 1993 to late 1990's) told me that as I get busy I need to actually scale back my hours.I might want to be in there 6 days a week, but as I got successful and busy I needed to scale back. I should be more efficient, my staff should be performing like a well-oiled machine, and I need to be fresh and focused for patients. Too busy over too many hours is not good for anyone.

Around 1994 or 1995, before I learned the importance of never just relying on one staff/front desk person (not having staff back up if someone goes kookoo - see above post) ; I lost my front desk staff and was seeing over a hundred people a week working 3 full days and 2 half days. I was able to continue seeing over a hundred people a week, and kept billing insurance and sending out other bills, for about a month - without too much stress - as my time was organized and I had specific time devoted to each "leg" of a practice.

I was taught to see a practice as a stool with 3 legs. 1 leg is patient care, one is financial skill and success (marketing, billing changes, investing etc) , one leg is future research (on both the other legs - new treatments, no equipment, better marketing). You need to spend some time on each.

You need to have regular office meetings. You ought to have something like an hour long meeting with some regularity. You need to have PPI's (personal production interviews) in which you sit down , one on one, with each staff member with some regularity (maybe once a month at first, and after you have worked together for a while maybe quarterly) and go over their performance and what changes if any might be made, always be sure to praise your staff about things at these interviews - even if there are some real problems.

But I also recommend you learn to schedule time for one minute meetings. Have a brief message on some urgent or timely concern - maybe the way a patient was handled that morning, or a problem with patients you never encountered before, maybe some personal problem in a staffers life you know of, maybe something like knowing phone service would be disconnected temporarily on Friday because the phone company needs to work on the lines, maybe a Medicare billing update that needs to be instituted ASAP. One minute in which to inform everyone, make sure they understand, get some feedback. But these meetings help your well trained employees to continue performing at high level. Sometime even championship sports teams need to learn new plays or review fundementals.

My Medicare based practice had a PTW of 8-10:30, Up time from 10:30 to 12:30, and up time from about 3 to 6. A family based practice of mine had up time 9-11, down time from 11-noon, up time again from 2 to 4, and then PTW of 4 to 6.

Having a slow patient show up in PTW (new patient, complex patient or patient that is known to be a time-hog) will throw things off. Some patients just always monopolize your time, even if you are good at managing patients - there will be some that just take a bite out of your time every time. Your staff needs to be aware of this, and keep things organized.

still to be discussed : handling emergency calls when out of office, and maintaining free time.

 

[Doowai]

That's more like it.

 

[Doowai]

Practice statistics : what numbers are important, what the numbers mean.

We often evaluate the progress of patients by looking at their numbers : heart rate, blood pressure, temperature. These numbers give us clues as to how they are doing. What numbers mean important things to us?

There are the big four that anyone should be able to figure out (in terms of business) : new patients, office visits, billing, collections. The big one for a business is collections. But there are other numbers that are important, and often give us clues to why you see changes in the big 4, and most importantly in the big one.

When speaking business, keep in mind collections is the bottom line. We can often get lost in many other statistics. Its like evaluating a medicine ..... lets say Vytorin ...... do we really care about triglycerides? I mean really bottom line? Would we care about triglycerides if your patients lived long (quantity) and high quality lives, feeling well and happy. I don't think anyone would care if their blood pumped pure triglycerides if they lived to be 100 years of age, full of vigor, mental acuity, happy, strong sex drive etc. Many numbers are superfluous if the bottom line (mortality and morbidity in health care, and collections in a business) is not being met - the adjunct numbers are all meant to help explain changes in the bottom line.

SO what other statistics are there that a health practice can (should?) be concerned with.I think there is over a dozen.
1) Total patients seen - includes new patients
2) total patients scheduled
3) Missed appointments (#2 minus #1)
4) % of missed appointments
5) rescheduled appointments - number of missed appts that were rescheduled
6) % rescheduled appointments
7) New patients
8) scheduled new patients
9) front desk collections - payments directly from patients
10) 3rd party collections - from insurance etc
11) Hopper time - time from when they sign in, until they are called to come back. Time spent in the waiting room
12) Prime time wave - what was the busiest hour of the day, and how many were seen in that time
13) recalls - should at least equal the number of missed appointments
14) Number of periodic re-exams, re-evaluations
15) services, billings
16) percent collections - collections devided by services. Calculate seperately the total percent collections, the percent that is cash and the percent that is 3rd party pay.

For my medical practice I am thinking of adding another one : 2nd hopper time. Seinfeld did a bit about when you visit the doctor you first sit in the big waiting room, then they call you back to what turns out to be the second waiting room. This is not so much a problems with chiropractors or physical therapists because when they call a patient out of the waiting room they often put them on traction, or to do their exercises. So even though the doctor is not with them, they feel like something is going on other than waiting. I don't know.,,,, but it sucks to wait in the big waiting room for 20 minutes, get called back and then wait in your private treatment/waiting room for another 20 minutes.

Missed appointments really should not be more than 10%. If a patient misses a visit and reschedules and keeps the appointment within a week, I count it as a kept appointment. But if people are missing more than 10% of their visits you have to figure out why : poor bedside manner on your part, too expensive, unfriendly front desk, too much waiting.

Really, there is no reason why every one of your new patients does not keep their initial appointment - unless you are oddly inaccessible, like on the Himilayas. If new patients are not showing up, it is 100% front desk problems.

Hopper time is important. And its an easy statistic to keep. Most offices have a sign in sheet already. THey sign their name, the time of their scheduled appointment, and the time they are actually sign in. All the staff has to do is then sign what time they are called back. From 1994 on, my hopper time averaged under 5 minutes (and around 1995 I was often seeing over 40 patients a day). A 2nd hopper time could be done easily - put an egg timer on the treatment room door. When the staff closes the door they hit the timer, the doctor hits it when they walk in - write down how long it took the doctor to get to the room after the patient was placed there.

I had a nephrologist, - always a horrid wait. One day I had to leave work early to keep the appointment. I waited 2.5 hours in the private treatment room. They left the door open. I listened to the nephrologist talk to a patient and his wife for 15 minutes about the magazines in the office and the patient tell him jokes. Okay that sort of bonding is fine, but during up time - not during prime time wave and certainly not when you have had any patients waiting more than an hour. Up time is for time hogs. But once anyone waits an hour you are going to irritate the heck out of patients. So I listen to him talk about plain old junk when I have been waiting and waiting and waiting - but finally he ended the long conversation with the patient. I was expecting him. Just then a patient actually walked back and said his appointment was not until 5:30 but he had a family member waiting for him at the airport and wondered if the doctor could just see him quickly now. The doctor took him in a room. And I left and have never gone back.

Don't make people wait too long.

Keep track of your PTW - if you see it is changing why is that. Why is your office dynamics changing? And keep your front desk appraised - they need to know to keep time hogs out of your PTW.

Your re-exams. You need to have some sort of tickler to remind you to do periodic foot exams or eye exams or A1C blood tests. You need to have some accountability on caring for your chronic patients.

Take the amount you service or bill and devide it into the amount you collect. Find out how much is cash and how much is 3rd party pay (insurance, workers comp etc). If cash collections ever drop off, make sure your staff is not stealing from you. If your insurance portion drops out, look at whomever is billing. But as I mentioned in a previous post on this thread, staff can steal a seemingly small amount (like $40 a day) and end up stealing a large amount from you in a year or two - so the superbill method of acounting for your money that I mentioned above, is also recommended.

 

[Doowai]

Number one practice building tip :

Again I am speaking according to my real life practice experience, and that is as a chiropractor. Hopefully in 5 years I can speak with more authority as an MD in private practice too.

But the number one easiest and most effective practice building technique is simply : when someone says anything good about your professionally, hand them a card (which you should always have on you the first two years) , touch them in some way (hand on their shoulder, hold their hand in a two hand handshake) , look them in the eye and say "Thank you SO much. That means SOOO much to me. After all my years of training and education, there is nothing that means more to me than one of my favorite patients saying that to me. Every doctor wishes their practice could just be made up of good patients. My experience is that birds of a feather flock together, and good patients have friends with other good people. I would love to have a practice full of people like you. Would you do me a favor? Here are three business cards. Would you give them to one of your friends or family that might need my services?"

People love to help. Especially if you are new to the town or practice, they will love to help you. They will not resent it at all. They will bring it up years later - I gaurantee it. They will say things like "Remember when you were new in practice? Remember when I refered my aunt and also Terry in to see you? You were struggling back then. You are very successful now". When they do that you need to thank them for their help, acknowledge how they helped make you successful. Then ask them to do it again.

If someone does refer a new patient to you, NEVER forget to thank the referrer. Its great if you hand write a 2 or 3 sentence note to mail to them, but at least mark it on their file so the next time they are in you can say thank you to their face. Better yet do both.

These two things, especially the simple business card request in response to someone complimenting you (even if it is on the first visit) will work to build your practice quickly and powerfully.

So simple, takes a bit of cheesy confrontation, but powerful. 20 new patients could easily become 50 more with little effort. Just like in a street fight, the simple things are often the most effective.

A note about sincerity -birds of a feather do flock together. If someone whom is difficult for whatever reason compliments you, it may be sometimes best to just say thanks.

 

[Doowai]

http://forums.studentdoctor.net/showthread.php?p=6506518&posted=1#post6506518

Some ideas on financing the purchase of an existing practice

 

[CuNon]

good thread. Thank you.

 

[DC DOC]

Wow! Good info, even for a Pre-med (but future FP). Thank You.

 

[Doowai]

Post #43 up above on office statistics is done. There is some fine points, but I am sure you can figure them out.

You want to get people in and collect money. The other stastics help you figure out what might be interfering with that.

 

[redsun2]

I think this thread is really very helpful! thanks!
And just have a stupid question, if you are the only doctor in that clinic, what happen if you are sick or have other emergency issue that you have to be absent for a long period of time? (like months) What can you do?

 

[Doowai]

My favorite marketing techniques were pretty simple.
1) Lectures - breakfast lectures, lectures at various clubs, having others give lectures in my office. The lectures that others did in my office I would advertise in the local paper for free by having the paper release the information as a PSA.
2) Handing out business cards
3) Newspaper

My newspaper ads were always a combination of logic and emotion. A double barrelled shotgun. The first part would be information taken from some study or report. Back in the early 90's most of the studies on chiropractic were outcome studies such as ones done by compiling result statistics from worker comp claims comparing surgical, medical, PT and chiropractic results - cost, and patient outcomes. Or outcome studies such as one done by the Rand corporation.

Later in the mid 90's several other studies were done, such as ones on Cox distraction. Its a dynamic physician controlled form of traction that has showed over 84% of lumbar disc herniations could be resolved (as demonstrated on MRI) with Cox distraction. It actually sort of sucked the extruded material back in. Now Texas Back Institute (the worlds largest freestanding medical treatment facility for back pain) has 2 chiropractors on staff in part because of this research.

In the late 90's and into the 2000's the peer reviewed JMPT (Journal of Manipulative Physical Therapy ; devoted to spinal manipulation) began publishing many peer reviewed studies on chiropractic (such as true risk of vertebral artery dissection, effects on scoliosis correction, etc) that are now archived in the National Library of Medicine on Pubmed.

I would write a short 2 or 3 sentence paragraph summarizing the results of the research - and I summarized it so that it did not just list the results of the study, but WHAT IT MEANS TO THE PATIENT. 84% chance of complete resolution of hernation means what exactly? No surgery? Pain free? In terms of ADL? Cheaper than surgery? If you use science, tell them what it means to them.

Then in the second part I would try to stir their emotion. I might use a brief testimonial from a patient - this was powerful, but this was before HIPAA. You can still use testimonials but you have to protect their privacy. I also might simply turn the study so as to indicate what it meant to them, in dramatic terms to motivate them. There was one study in which they took a large number of pain free athletes. They evaluated them in terms of 11 athletic variables like flexibility, endurance, reaction time etc. Half of them received regular adjustments half did not. Those that got regular chiropractic adjustments improved dramatically in all 11 variables compared with the non-treated control group. I don't remember the specifics, this was about 15 years ago. Anyway, I then explained something about what this meant to the group I was targeting. I don't remember who it was directed at - I have a notebook of all my newspaper ads, but have not looked it up - but it might have been about having top athletic performance if it was sport season time, or it might have been about possibly more days at work without injury (it was a very blue collar, labor intensive, farming community).

I also ran ads about topics that meant something to me that had nothing to do with Chiropractic. I am sort of an environmentalist, so I always ran an earth day message about things we could do towards conservation. I started this back in 1991.

I also had a few local celebrities that allowed me to use them. One was the national intercollegiate calf roping champion - he and his family went back in the town to its earliest days. His great great great relative was the first person hung in the county for horse theiving something like 200 years ago. People really loved and respected their family. He gave me a photo of him wiping out at a rodeo - the picture was taken as his horse was flipping and he was about to hit the ground. I asked his permission to use it, and I put it in the paper with a cartoon-like balloon caption coming out of his mouth saying "Oh no, I better call Dr.Doowai". That ad alone brought in alot of people. At the bottom I used a written quote he gave me permission to use that said " Dr.Doowai has been my chiropractor for years and his treatments and the exercises he has given me to do helped me with the Rodeo championship".

I felt a good headline was very important. Something that grabbed them in the first few sentences.

Two that I have seen (that i did not invent) was one that said "If your spine was on your face would you take better care of it". The other one was an ad another chiropractor ran that read "Local chiropractor admits : I AM GUILTY" - and then the ad went on to sell something about his office using his "guilt" as a springboard, but I felt it was a very attention grabbing ad. I am sure lots of people would love to read about a chiropractors guilt. I think many people would love to read about how stupid a medical doctor is (since there is so much belief that medical doctors are so smart) - maybe something like "Local MD is actually very stupid" , which then goes on to read something like "I am so stupid because I added botox injections to my services and I forgot to tell anyone. So for the next 30 days all of our Botox injections are only $8 per unit." Or other headlines like Local MD caught cheating ,etc

Ads should have a "call to action" - this is a close that is used to suggest the reader does something now. Its designed to induce action. Such as "Botox at $8 per unit for 30 days". You have to be careful that your inducements are not aimed at getting medicare patients to come in - its a Medicare violation to offer financial incentives aimed at medicare patients to come in such as "free exam to see if a hip replacement for DJD is right for you" or "free prostate exam to see if you would benefit from a TURP". I myself have never liked offering free or discounted services, and always hated to see other chiropractors do it. I think it cheapens your services. I prefered simple call to actions like : Call today at 333-333-3333. Or repeating the main theme of the ad - if the ad had to do with sciatica, more specifically something like : if you or someone you know is suffering from sciatica, don't waste time, call today to see if chiropractic might help. But like asking children to take out the trash, you often have to give a call to action, make it clear you want them to do it by a specific time, or better yet now.

Pictures help print ads.

 

[Doowai]

Using the media for free advertisement :

When I was doing general surgery rotations, the general surgeon I was with was interviewed on TV for the Susan G. Komen Cancer Foundation. She does alot of breast surgery for cancer. She has taken extensive continuing ed courses on special procedures that help preserve and restore natural breast contours after extensive lumpectomies, and has written papers on special biopsy procedures. They interview her several times a year. They are lengthy interviews on the big channels here. They give her name and then she delivers a public service announcement on this plastic sheet women can use to make self breast exams more accurate, or whatever.
I told her she needs to at least, along with her name, give her office address and her phone number. Her phone number both at the beginning of the piece ("we are talking with Dr.Surgeon, who can be reached at 333-333-3333."). And then again at the end of the piece they ought to give her phone number.

I also recommended she offer something free of charge. Like she could buy a bunch of those little plastic things that women use to do breast exams, have her office name and number printed on them, and the TV channel can give a contact number which viewers can call and recieve one of those for free - or perhaps the first 100 callers.

She ought to use the time to at least briefly mention the special surgical procedures she can do to reconstruct the breast - its a real benefit to people, and they ought to know where they can get it done. The breast reconstruction she kind of shifts the remaining tissue around to get a natural breast contour - and she charges nothing more to do it. She took the course in Italy, and it takes like an extra half an hour, but she includes it for free. I think people ought to know the extra value they get, and why they ought to go to her. When she is doing her report of findings on patients, and tells them what she is going to do - she never was telling patients about this special service she offers. She ought to make sure they know they are getting that so that she gets the "wow factor". Patients should think : Wow, I am getting some breast reconstruction for free!".

Here she regularly has the opportunity to tell lots of people about her. It does not need to take more than a minute or two. but she ought to do it. Its free advertising. Do you know what companies pay for a one minute commercial on a major local network?

Everyone ought to write and memorize a few one minute or 30 second sound bites about themselves. Not : I am Dr.So-and-so. I do surgery. That builds no value. Instead something like : I am Dr.so-and-so. I work primarily with breast cancer, and specialize in breast reconstruction using the womans own tissue, for more extensive lumpectomies. I do this free of charge. I saves the woman time and money since I just do it at the time of the lumpectomy, and it helps their breast look normal; even after extensive removal of a lump. THese are not just used when on TV or the radio, but when standing in line at the bank or at parties, when someone asks what you do.

When I was in practice I used radio stations every now and then. AM radio expecially likes to interview people. If you had some special counterpoint to the Vytorin issue, you could call a few radio talk shows and introduce yourself, and tell them that you have some important information about the Vytorin issue that is being overlooked by the media. You might have to prepare the area you are going to farm by first sending a fax that shows a news release about the Vytorin issue, since they may not be familiar with it. You probably want to send it to the programming director. They want controversy. I did this at one radio talk show. They invited me in - sure we want to interview you. Literally 30 seconds from air time the guy interviewing me turned to me and said "Hey, do you mind if I ask you some questions about chiropractic and safety?" I had brought some facts on that , so I smiled and said "No, I would like to discuss that". "Good", he said, "My son was recently paralyzed by a chiropractor and I would like to talk about it also". Gulp. His story was true. A local chiropractor in that town, had invented a technique he called a "knee neck manuever" in which he put his knee on the back of the neck of a prone (face down) patient, and wrapped his hands around his forehead and stretched his neck backwards. It resulted in a messy lawsuit the chiropractor lost - since it is not a technique taught in any chiropractic school, he made it up (laws in most states require chiropractors use techniques taught and accepted in accredited chiropratic institutes).

So just be aware , radio stations especially, love controversy and it can be at your expense. But don't underestimate AM's listening audience. One time a magazine article I wrote got attention and a radio station that simulcast to 18 different stations asked to interview me. I was in the midwest but one of the stations was in Arizona. I called my best friend and asked him to listen, as I told him I would work his name into the interview (lets call him Ricky Bobby). During the interview I said, Ricky Bobby of Arizona has been working alot on discovering a cure for erectile dysfunction, primarily because he has suffered so much personally from it. He thought it was funny, it did cause the interviewer to pause since it had nothing to do with the topic, I just was having some fun. But even though I was in a little town in the midwest, my voice was heard 1500 miles away.

News papers , as I have mentioned, will do PSA's to announce a special speaker at your office who might be speaking on "dealing with troubled teens".

Do you have a new state of the art piece of equipment? Did you just get some special training in a new treatment? Do you have speial knowledge on a hot topic? Did you win an award and may they want to interview you? It might even be for something unrelated to medicine - I knew a guy who was an Olympic lifting chiropractor and got alot of media attention because of an international competition he won.

What do you have that might be newsworthy? Do a good job once (meaning be someone that makes people listen - think Oprah), and they will want you back.

I never did any huge advertising campaigns. Was not the type to give out coupons. I was in a town of about 3,000, 5000 in the county. There were 2 other chiropractors there, and 2 osteopaths that did manipulation. I had over 3,000 individual patient files - and drew regularly from 3 counties, but had several patients come from other states.

I never badmouthed another chiropractor. That is NOT a good thing to do. Md's badmouthed chiropractors for years and I really think it helped out business - now that MD's are more accepting I swear its not as good. People side with underdogs, people like to come to the rescue - mudslinging will always bite you in the ***.

I used this in a town of about 3,000. Statistically 11% of the population see chiropractors. That means there should have been about 100 patients for each of the chiropractors in that town. When I left that town I had over 3000 individual patient files - even though many came from other counties and even other states. WHen I moved away, my very first patient I ever saw would come to see me if they had an ache or pain. I did nothing other than what I have mentioned here to build a practice (except for what I call internal marketing). Granted it was a small town - but I had a practice in Phoenix for 6 years, and it was successful, and I did nothing other than what I have already mentioned.