I'm just going to tell you something you're probably not going to need to pay a lot of attention to right now because you're probably not going to see any of this. Unless you go into a private practice, unless you're running a business, you're not going to pay a lot of attention to this. But I'm just going to tell you some of the nuts and bolts about what it is like to manage a practice. First of all, it's a practice, it's not a business, but you've got to run it like a business. You're going to take care of patients, but you're not going to succeed and collect any money unless you pay attention to what's behind the curtain. But you don't want everybody else paying attention to what's behind the curtain. You want them paying attention to you and your staff. You don't want your patients to think it's just a business. But it is. If you're going to be in a private business, it's got to be successful. How do you manage it? Well, you have a plan, a strategic plan. You've got to routinely make rounds on your financial performance. We used to do it. Now, again, I'm in a hospital, I don't do this anymore, I have to keep reminding myself I'm not in charge. But when you are, you watch the money, you watch your financial reports. We would do it every three months. I visited practices where they did it every month. And sometimes if you're in a crisis about something, you're going to have meetings every week about something. Don't meet just to meet. Meet because there's a reason. Everybody's busy and they've got other things to do. Communicate with everybody. If you're the manager and you're in a small practice, you get things done really quickly because everybody understands what's going on and you're explaining and talking to them about it. Nobody's in the dark. But you've got to practice manager. Don't get in the way. Don't micromanage. If you're the manager, you let the manager manage and tell you what's going on. Don't get in the way. Then employees get confused. They don't know what's the line of authority. They keep coming to you. You don't want that. You go to your manager. Okay, so what's in a regular business meeting? You look at a lot of items like your income expense statement and all those things there. You've got to know who's paying you. How much are your receivables? Are you collecting 45 days AR average or is it 120 days, 150 days? Why aren't you collecting your money? If you're not paying attention to that, you're losing money. Some of those won't even come in. Days outstanding. Productivity, where are you getting business? Where are you not? Why are you not getting business there anymore? And then special items and strategic planning. It's really simple. It's a real simple equation. Katie's gone, but I agree. I knew subtraction and addition. It's all revenue that comes in and expense goes out and you get what's left. That's how it works everywhere. Now when I'm being in a hospital, the hospital has to figure that out and they give me my share by contract, but when you're running a practice, you've got to balance those things and you want to look for things that will give you more money coming in and less expense if possible, but never, never, never, never save money by cutting expenses where you can't get things done like getting rid of one or two people in the office and then you can't get any phone calls coming in or you can't get any appointments made or you don't get the billing done. You got to have enough. You got to spend money to make money. You just got to watch the way the efficiency of the business and how it's being done. I've always thought if you don't get people in quickly, they're going to go somewhere else unless you are really brilliant and you got the greatest reputation or you're not going to start out that way. Be available. If it's more than a week, they're going to go somewhere else. In a private practice, I think it's good. You're going to be doing a lot of everything, but you want to build your reputation gradually on something that identifies you and you get recognized for. Now you may do that fellowship and you may go into that practice and, well, you're just not doing very much of that. It may take time, but you got to aim for that, I think, to be most successful, especially in a competitive environment. A successful private practice, I mentioned this before, makes up for the loss or the cuts in revenue by having ancillary alternative income sources. Rich Williams is one of the most successful at this. ASC Venture is one of the most successful ways of doing that. Now some things you can't change. You can't change laws. You can't change federal fee schedules. You can't change the general economy. When the general economy goes down, visits go down, some, although health care tends to be the least affected by these changes in the economy. Work with factors under your control, things that you can do, your services, how efficient you are. Are you able to see 30 patients in a day or only 15? Well, if you can only see 15, you're going to make half as much. Bottom line, half as much. And you can look at what you're being paid, try to negotiate fees. Some you can, some you can't. Small practice can't negotiate much very well. Look at how efficient your office is and your office expenses. CPT, that's what you need to know. But after CPT is correctly done, it's still got to go through a submitted claim. The claim's got to be correctly submitted. If it's not, it comes back, it gets thrown out. We always found that a commonly, Humana, United, 10% would come back. They just throw out one in 10, they just throw it in the trash, and you've got to do it again. Why? I don't know, but if you don't pursue it, it's gone, it's gone. You've got to keep looking at those EOBs, everybody knows what an EOB is, right? Explanation of benefits, you ever been in a hospital? Well, they send you an EOB, they say, what was paid and what wasn't? As an office, you want to know what that payer paid or didn't pay and why, and dispute a lot of these payments that were rejected. You've got to look at your EOBs. This silent PPO, ever heard of that? Something like Beach Street, an insurance company or a payer will contract with a network, a national network, Beach Street's one of them, and they rent their fee schedule. You think you're getting paid one thing from this payer, and they pay you at a lower rate, and you say, what? It's silent PPO. They've rented somebody else, who you contracted with for some other service, maybe with a small business. That's the way it works. File accounts receivable, look at your EOBs. Your personnel costs are over half. Make sure everybody's being used well, so their benefits are about 20% above their salary. Make sure the benefits that you're giving are good, but that they're not out of line. Make sure that your staff is cross-trained, because otherwise, they're sitting around doing nothing, saying, that's not my job. There's a lot of that that goes on. It's not just in medical offices. Yes, it is your job. You don't sit there when you have nothing to do. You do something else. Make sure you cross-train your people to do that. Pay them well. It costs a lot to lose people, because when someone comes in, they don't know what to do. It takes them a while to get geared up. Your office is inefficient. Pay them well and keep them, but make sure they're busy. Make sure the space you're paying for, you're using. You're going to have to have a bank know your banker. You're going to have retirement plans and a trust that's going to have to be managed. You're going to have to take out loans. You're going to have to have an accountant to do all these things, including helping you make your corporate decisions and whether you make investments or not. You're going to have a lot of different kinds of insurances, not just professional liability. You've got general liability. What if someone trips coming into your office? DNO. You know what DNO is? Directors and Officers. Well, if you're a director of your corporation and it gets sued, if you have insurance, you don't have to personally pay the liability of that company or corporation, professional corporation that you are an officer of. DNO insurance. Disability is a little harder to get these days. You're going to need attorneys for multiple things. We already talked about the malpractice, but that's not the only thing. You've got a lot of regulations you've got to follow and know you're doing the right thing. You have your professional service contracts, and you've got to know what you can and can't do with your employees because there's employment law, and you need someone to help you sometimes with that. A lot of medical records. That was what my office looked like on the right side. Well, no, that's not going to be it anymore, so I'm not even going to tell you about medical records. I don't even know about it. Supply costs. I mean, serious. Supply costs. Watch. Get bulk rather than single payment. Get bulk discounts. So you've got to look at your efficiencies. Look at your benefits and all this. This is not something you remember. Look at your facility costs. Are you using all your space? Is it efficient? Do you have satellite clinics? I go to a couple of satellite clinics. It helps me bring in patients because I'm identified with that region. I'll drive 150 miles to a clinic and spend all day there, but a substantial amount of practice comes out of that, and without that, you don't have any real contact there. And if you're in a private practice, they're more likely to look to an institution and its reputation than you and send it to the institution. In a private practice, you want to be known. You got often to go and meet and be present. I believe that it is still true with all the Internet and everything else that your referrals come from those who refer people. Those are doctors and PAs and nurse practitioners. Those are the most important contacts that you have. Everything else is secondary. Any chance to see and personally talk to one of these people, you've got another new friend now. It's not just a jury. You've got a referral source. They know you. Doesn't mean you have to talk to them every day, but just to talk to them one time so they know you, it helps. And then you build your referral network, make personal contacts. All these other things, sure, patron recommendation does make a difference, but this is the most important thing. Your reputation. We've heard this before. That's your single most important possession. Treasure it and build it. So you got to decide on what your goals are. Depends on what your values are, your own beliefs. Your goals should match. You'll be happy if they do, but you got to do it in a business fashion. You got to have goals. See are you achieving your goals, revise your plan, and make sure you know where you're going. Otherwise, you're all adrift. And that's all I have to say about the nuts and bolts of management.

medical practice

efficiency

business

patient care

strategic plan