On Making Decisions

Perhaps I made a mistake on VONAGE. Perhaps. Only when I Look back 21 months later, with the benefit of hindsight, am I not so sure that I would use this company again. But then again, 21 months ago I was in a bind and VONAGE was the perfect solution at the time. I had just left my old group and I wanted to capitalize on retaining any former patients of mine into my new, fledgling practice. I had no office and was unsure how long it would take me to get an office. Every day that I went without an office was lost money and missed opportunities. I was desperate to get new patients and was unwilling to miss a single one. With VONAGE, I was able to set up shop in my home and function as a business well before I had an office or an exam room or a staff. For me, back then, VONAGE was a key ingredient in my early success.

Some say that VOIP is not reliable for mission critical functions related to business. I disagree. Many businesses use this technology and it works very well. I have friends in the financial service industries—on Wall Street—whose firms have switched to VOIP. What is more mission critical than high finance? The problem has not been VOIP, but customer service at VONAGE. Their technology is fine. It is their service that fails.

It is very easy for people to criticize and second guess the decisions of others. It happens every day. What the critics fail to realize is that we make decisions with the circumstances and the best available information at the time, not years later. I believe the ability to have vision and then use it to analyze a situation, cull the data, and be decisive given incomplete information is what separates successful doctors, lawyers, politicians, and police officers, among others, from unsuccessful ones. Teddy Roosevelt understood this:

"It is not the critic who counts: not the man who points out how
the strong man stumbles or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes up short again and again, because there is no effort without error or shortcoming, but who knows the great enthusiasms, the great devotions, who spends himself for a worthy cause; who, at the best, knows, in the end, the triumph of high achievement, and who, at the worst, if he fails, at least he fails while daring greatly, so that his place shall never be with those cold and timid souls who knew neither victory nor defeat."

Critics will always be out there in the ether doing what they do. My advice to another person who finds themselves solo and unsure of what to do: analyze and think, but don't be afraid to make the hard decisions. And to hell with the critics!

Thanks for listening,

The IU.

VONAGE bites me in the ass!

Several months ago I switched from VONAGE to my local VOIP phone provider due to reliability issues. I ported the number and everything seemed to work out well. I did test to see if the port worked by simply calling the number and voila', it rang in my office, call hunted, etc. Beautiful.
Yesterday I received an email from a former patient of mine. "Dr Schoor, are you still in business? Your phone number has been disconnected for weeks" went the email.
What? The phone had been working fine and was ringing off the hook that very morning. I called him.
Apparently he has a VONAGE system himself and when he called from his cell phone or any other non-VONAGE phone, the call placed successfully. But from a VONAGE phone, the caller would always receive a disconnected message. I called VONAGE.
"Oops, sorry, our bad. We forgot to release the number from our system. I'll do that now. It'll take 24 hours. Sorry for the inconvenience."
Holy shit!!! For 3-4 months, anyone that tried to contact me from a VONAGE phone would not have been able to do so. Un-!@#$%-believable.
Think of the missed opportunity costs. I estimate that I probably missed 3-5 prospective new patients who called, got the message, and went to the next urologist on the list. Being that new patients are worth, over the course of a year ~$400, I can estimate a loss of up to $2000, maybe higher.
Yeh, I'm pissed!
My recommendation: if you are a business, do not get started with VONAGE. Their customer support is just not adequate for a business's needs.

Goals for -08

My 5 Areas of focus, (not in order of imortance)

Process Sreamlining ---Revenue Generation---Cost Containment---Safety---Payer Shift

At the beginning of a new year I like to take stock in what I have accomplished and to focus on goals for the next year. The cycle above represents the 5 major areas that I will focus on most. All are interrelated and of equal importance. For example, streamlining processes will result in increased patient safety and efficiency and help to decrease costs. Revenue generation will follow based on an increase in word of mouth referrals and through acquiring patients with better paying plans and cash pay.
Wish me luck.
The IU.

Just Doing My Part

 

 

Take Action Now!

 

Dear Patients,

New York State is currently in a health care crisis that threatens all of our abilities as patients to get affordable healthcare. The threat comes from a tort system in New York that has run out of control. Jury awards have risen dramatically over the years and are often out of proportion to the nature of the injuries. The problem is only getting worse.

I support tort reform that retains our rights to seek reasonable compensation when injured by a negligent act, but the system must prevent excessively high awards for pain and suffering that is limited in intensity and duration.

I call on you to take action and contact your local representative in the state assembly and ask them to support liability reform. I have pre-printed, addressed, and stamped envelopes; all you need to do is sign.

Please become involved in this grass roots effort to save New York from an impending health care implosion and in doing so, help to lower health care costs for the majority.

If you have any questions, please feel free to contact me.

Sincerely,

Richard A Schoor MD FACS

Taking Notes From a Plumber

I just had a great experience with. . .a plumber! Yes, that is right, a plumber. And I paid $680. How is that. Well, I took notes. Not on his plumbing technique, but on how the business was run. Terrific from first contact to last. Let me tell you about.

We have a leaky pipe in the basement of our house. Though we have a contract with a plumbing service for our boiler and AC, I forgot their name and did not feel like looking it up. Plus, this pipe would not be a "covered" service anyway. As I was about to blow off the whole thing for another day, my wife handed me my 5 month old and a flier from a plumbing company. I get tons of these things, but timing is everything, right. I looked at it and liked the message: on-time service, up-front pricing, no surprise or hidden costs, all credit cards accepted, all work guaranteed in writing for 1 year (that's hell of a global), and a coupon. On the bottom of the flier was their phone number, clearly visible. I called—7:15AM—and, voila, they answered. Sold!

Over the phone, the receptionist had a friendly voice and she offered me a number of scheduling options, that day, or any other day. She had one of those great phone voiced that makes you feel like she is on your side. I should have offered her a job. Anyway, I took an appointment for the following morning, between 8 and 10AM.

At 8:30AM, the plumber arrived. He parked his truck so to not block my car, and when he entered the house, he had his own door mat with him. Nice: makes for good style points. I showed him the problem, along with several others that have been lingering, and after an inspection he came up with a solution, a guaranteed price, and the 1 year guarantee on the work. Plus, he turned off some pipes to the outside, gratis, and wore shoe covers so he would not dirty the rug. Again, nice style points and demonstrated that he was on my side and cared about details.

The work was completed quickly, but not too quickly. He made a soft up-sell on some biological cleaner, and I declined, and here's the kicker: when it came time for payment, we completed the transaction with a mobile, cellular credit card processor. Payment to him guaranteed. No accounts receivable. Not only relatively painless to me, a technological talking point.

Lessons for the doctor.

1: Answer the phones.

2: Hire excellent phone personnel and train them well.

3: Make the patient know that we are on their side.

4: Embrace technological advancements, especially when it comes to accounts receivable.

5: Attend to the details. They really matter.

Anyway, thanks for listening and if you want their number, send me an email.

The IU.

What Medicare cuts could mean

It looks like Congress will not intervene and that Medicare cuts of 10.1% on average are imminent. Urology is slated for an 11% cut. What does this mean in real dollars. Let's take a look.

 

Practice A sees 1200 patients per month = 14,400 visits per year x 25% Medicare = 3600 Medicare visits per year x average visit value of $150 = $540,000 reimbursed per year from Medicare x 11% = [$59,400 - $540,000] = $480,000 lost income if Medicare is dropped completely.

Practice A sees 1200 patients per month = 14,400 visits per year x 10% Medicare = 1440 Medicare visits per year x average visit value of $150 = $216,000 reimbursed per year from Medicare x 11% = [$23,700 - $216,760] = $193,000 lost income if Medicare is dropped completely.

 

Practice B sees 400 patients per month = 4800 visits per year x 25% Medicare = 1200 Medicare visits per year x average visit value of $150 = $180,000 reimbursed from Medicare x 11% = [$19,800 - $180,000] = $160,200 lost income if Medicare is dropped completely.

Practice B sees 400 patients per month = 4800 visits per year x 10% Medicare = 480 Medicare visits per year x average visit value of $150 = $72,000 reimbursed from Medicare x 11% = [$7,920 - $72,000] = $64,080 lost income if Medicare is dropped completely.

 

Practice C sees 200 patients per month = 2400 visits per year x 10% = 240 Medicare visits per year x average visit value of $150 = $36,000 x 11% = [$3,960 – $36,000] = $32,040 lost income if Medicare is dropped completely.

 

So as you can see, the numbers are large indeed whether a group or solo urologist keeps or drops Medicare. However, based on my calculations, a urologist or urology group would still do better remaining par with Medicare. Out and out dropping of Medicare would be tantamount to suicide for the business.

Though it is tough for me as a urologist to admit, Medicare has me by the balls.

Good luck to everyone else.

 

Speak of the devil.

The new HIPAA rules for practices such as mine.

Can't wait to read through them.

Results of my survey

I just sent a survey to an admittedly un-scientific sample of my patients, yet the results were interesting. The survey, sent to 24 patients selected at random, asked respondants 9 questions relating to the practice, the patient's experience here, and asked for suggestions for improvement. Here is a preliminary result that I'd like to share with you, as I find it interesting.

• 16 out of 24 respondants stated that email was their preferred method to communicate with the doctor or staff, and this was not age dependent.

• 24 out of 24 respondants stated that they had NO concerns regarding email security.
• 24 out of 24 would refer me to a friend or famlily member.

Interesting. I am not sure what it means, but I believe that:

• HIPAA is perhaps a bit overblown.
• People want to communicate by email.
• I'm pretty awesome.

I plan to send more surveys to try to get some real scientific data with hope of publishing it here on my blog.

Until then,
The IU.

The Paradigm Shaft

Several years ago a wise man said something to me that really impacted my life. He was a Pharma drug rep, but prior to that, he was an accountant for a financial service company. One day, during his old career, he had an epiphany of sorts when he was conversing with an investment banker. The accountant lamented to the banker, "How come you make so many times what I make?" The banker responded, off handedly, "Because I make money and you cost money."

"Because I make money and you cost money." Wow!

Several weeks later, this accountant left his company and went into sales so he could "make money."

He told me that story over dinner one night and I had epiphany of my own. There are 2 types of people in the world: those who make money and those who cost money. People that make money will always be worth more than those who cost money. Most of us fall into the cost money category. Think about it. The dichotomy really has truth to it. Movie stars, investment bankers, top professional athletes, even top doctors and lawyers, all validate their incomes because they produce wealth for others as well. They make money. Nurses, medical assistance, accountants, teachers, police officers, fire-fighters, in fact most of the rest of us, are in more of a support role and don't really bring in the bacon. Not to say that our jobs are not important. They are. It is just that we cost money, rather than make it.

Doctors used to be in the "make money" category. Throughout the 1960's, 70's, and 80's, doctors not only made money, we were seen as having the ability to generate wealth for others. The perception was that we made money. Beginning in the 1990's--though it's roots actually started under Nixon & Reagan--physicians came to be seen as cost centers rather than revenue centers. This shift in perception, a paradigm shift really, put us in the very precarious position we sit today. In fact, to the extent that there has been the downfall of doctors, this paradigm shift led directly to it.

People that make money are always worth more than people who cost money. It is really that simple.

Again, I don't have a solution for the problem. I only have the observation. I suppose that if you are a physician, you may benefit from re-tooling your practice so that you can be seen as a revenue generator, rather than a cost center.

Remember, 2 types of people exist in the world: those that cost money and those that make money. Try to be the latter.

Good luck.

The IU.

Why I Hate No-Shows

For most of us in the service industry, no-shows are a part of life. For most of us in the service industry, no shows are an exasperating and costly part of life. People that no-show don't think it is a big deal. Here's why they are wrong.

1: Lost revenue: I see patients sparingly on Saturdays, ie I reserve the day for people that really have a difficult time making it to my office any other day. This Saturday, I had office hours from 8-11, staffed by 2 people x ~$28 per year = $84, not including my time. I had 4 no-shows, each worth ~$50 x 4 = $200 lost revenue for that day. I saw 4 other patients, 2 new and 2 follow-ups = $350. Total income for this day was $350- $84- $200 = $66. Now it may be worth my time to come in to the office for $550 - $84 = $466, but not for $66.

2: Increased liability: Unlike people that no-show to a restaurant, established patients that no-show to a doctor's office can cause future problems for themselves and for the doctor. Even though they--adults all, mind you--no-showed, it is our—the physician's—responsibility to make a reasonable attempt to contact them. To do this, we have to pull their charts, review them, make phone calls to the patients, and send them certified letters. What does all this cost? It costs a lot if you factor in the following: chart review = 10 minutes per chart X 4 charts = 40 minutes x my time + staff time to call x 4 + certified postage $5.39 x 4. Plus, a no-show patient that is lost to follow-up yet resurfaces several years later with a tumor that "you missed" can bankrupt you. No, no-show's ain't cheap.

3: Increase in uncompensated work: All of the above work by the doctor is uncompensated.

4: Inconsiderate: I call to cancel reservations at restaurants and for haircuts. It's just the right thing to do.

Thanks,

The IU.

Damn December

December! Everyone loves it, right. The holidays, parties, joy, peace and love on earth.

Bahumbug!!

The holiday season can be a difficult time for many people. The depressed or lonely are the obvious people that come to mind. But I'm talking about the small business owners. Whether you are in retail, food service, or health care, the holiday season brings many challenges to your business. In retail, for example, experts project poor sales for this year, and owners, managers, and employees of retail chains and mom & pop stores alike may suffer the consequences.

Medicine, contrary to what I was told as a pre-med student, is far from recession proof. In medicine, we suffer right along with everyone else, minus the insurance execs.

I am not going to get into the economics of whether or not we are in a recession. We are, however, in a period of difficult economic times for many people. This economic downturn, in addition to consumer pressures that the holidays bring, mean less money spent on health care. i.e., we, the doctors, suffer.

Let's take the example of a typical patient of mine, a 35 year old man who wants a vasectomy. He works for someone else, most likely a big, faceless corporation or government agency, and his employer pays for his health insurance. His family income is $150,000 per year, which does not go very far in the New York metro area. Like everyone else, his co-pays or deductibles have risen dramatically in recent years. Far from being 5 dollars, now they are in the $35 to $50 range. His children, like my own, have had one cold after the next, after the next, and he has paid several hundred dollars in co-pays for his kids' pediatrician visits. His oldest daughter wants a new dance leotard and a Webkins doll for Christmas and his younger girl wants a Fiona doll and a Bella Dancerella video. Perhaps he and his wife agreed to not spend money on each other, but knowing that this really means "get me something," he buys his wife some inexpensive jewelry and plans to take her out for sushi. On top of all that, the pre-school/day care tuition for his toddler is due by Jan 1, or else, and that ain't cheap.

So how does this affect me? Well, he and his wife have decided that 2 children are enough and that he should have a vasectomy. Most likely, his insurance will cover it. But he still has co-pays. And I don't waive those. I simply cannot do that. Since he has all these other bills to pay, does not relish the idea of paying the 2 or more co-pays required for the vasectomy. In addition, he can't afford to take any time what-so-ever off from work, even though vasectomy patients recover quickly. He thus decides hold off for now on his vasectomy.

Multiply this times 20 vasectomies per month, times God know's how many other elective things that I do in urology, and you can see why December can be a difficult month for a urologist or any other doctor.

But Happy Holidays.

The IU.

Cost Consciousness and Medical Practice

An interesting article in the NYTimes on air travel reminded me of what has become of the experience of seeing a doctor. Basically, the article talked about levels of service on airlines and who gets what type of service and why. In the airline business, the overwhelming majority of travelers chose carriers based solely on cost. I include myself in this category. As a result, we have become loyal to the price of the seat, rather than to the airline itself. The airlines know that our loyalty and our business come only with low fares, and that our business will leave with higher fares, and they have determined that keeping us happy is no longer important. Now, the airlines can cut out perks that once made flying enjoyable, or at least tolerable. The fact that we complain privately and publicly is not important, since they can always get our business back by running a special deal. On the otherhand, people who are willing to pay for business or first class get treated like royalty. Wine, no lines, chateau-braind. Very nice. While both coach and first class passengers arrive at the destination at the same time, the high paying customers have a better experience.



Like the airline industry, people that can afford better care, either on their own or via the best of the best insurance plans, get better treatment. They can be seen without referrals, go to out-of network providers, and get any medication the doctor prescribes. They can even go to a concierge model physician practice. This is like flying business or first class. For the rest of us, we have to fly coach.

The costs associated with running an airline have risen dramatically over the years. So has the cost of administering health care or purchasing health insurance. In the airline industry, at one end of the spectrum low cost carriers exist that cater only to the cost conscious traveler. At the opposite end of the spectrum is the corporate jet industry that caters to the high end, low volume traveler that cares solely about convenience and comfort. In the middle, we have the typical airline company, like United Airlines or American, that have first and business class for the "out-of-network" travel and coach for the rest of us in-network only customers.

Comparing the airline industry to the medical profession is easy. Flying low cost only carriers is like going to a clinic. You'll get to your location, or get your care, but it won't be pleasant. Flying business class or first class is like going to a concierge medical office or a medi-spa. Not only will you get to the location, you'll have a great experience on the way. Flying coach on a major carrier is like going to the typical doctor. It used to be nothing fancy, nothing great, but pleasant enough. Now it is horrible. As the airlines get squeezed, and as the doctors get squeezed, and as we the consumers let everyone know that we care only about cost, the experience is becoming less and less tolerable.

I don't have a solution for any of this. It is just my observation. I suppose that if you want premium medical care, like air travel, you will have to pay for it yourself. Otherwise you can join the rest of us in the coach section of modern medicine.

The world's cheapest full featured EMR-PM

Since my last post on my DIY EMR, readers have given me tips on how to make it even less costly. How does $0.00 sound for the software. Here's how:

• EMR/PM platform: openEMR
• VOIP Phone system: YATE.
  

• PDF generator: PDF creator from sourceforge.
• Word Processor: For MAC users, Bean. For Windows users: AbiWord.
• E-faxing: Fax digits.
• Accounting software: Gnucash

This list ought to get you going and leave enough cash left over to pay the insurance bill.
Good luck.
The IU.
Disclaimer: While I have tried some of these programs, I vouch for none of them. I have no affiliation with any of these products and can not attest to their functionality or security.

MS Word & Your DIY EMR

Here are some features of MS Word 2007 that make it so attractive for a homegrown EMR:

• Insert signature line: once inserted, you can sign it with the stylus. The program then locks the document to prevent any changes.
• Built in PDR conversion tool: No need to buy acrobat. PDF is a great format for an EMR for a variety of reasons.
• Insert inbedded files: The user can easily insert inbedded files, like bitmaps, with things such as illustrations, photos, notes, etc.
• Change tracking: This feature is also on older Word versions. Allows the user to make changes with cross-outs, rather than erases. Makes for good transparency, ie spoliation accusation resistant.
• Can easily create templates and record macros.
• Phrase finishing: user can train program to complete phrases and sentences. Useful when documenting encounters quickly.
• User friendly: very little training required.
• Ubiquitous: Is pre-installed on most computers, and is compatatble with google documents and MAC OS.
• Inexpensive.

In other words, it is an excellent tool for the homegrown EMR. AND, from what I've seen from many vendor sold EMR's, the basic platform that they use in their products. Kevin's right: why pay so much more?

The IU.

DIY EMR: The essential elements

It's been almost 2 years with my homegrown EMR. Works great. For any of you in the 'sphere who might want to do as I have done, here are the essential or helpful elements:

• Tablet PC with Windows XP Tablet edition
  
• MS Office Suite 2007
• Adobe Acrobat Reader
• Efax Pro
• Canon Multifunction F80 scanner/copier etc with included software or other brand
  
• Cardscan business card scanner with included software
• Linksys VPN manager
• MySecureDoc encryption software
  
• 1 DVD writer
• 1 external hard drive
• 1 off-site automatic back-up facility
  
• Your own courage to go for it!
  

Optional:

• Adobe Photoshop Elements
• Adobe Acrobat Standard
• OmniForm

All the above is off the shelf, inexpensive (relatively so) and easily customizable and scalable. Each of the above programs are also very powerful and user friendly.

Give it a whirl. Let me know what you think.

The IU.

Going Green in Medical Practice

With all the talk about the environment, I was wondering how one could "go green" in a medical practice. Here's how.

• Go paperless/EMR


• Set the computers to power saving mode


• Recycle shredded paper (even a paperless office has some paper!)


• Practice the judicous use of antibiotics


• Install water saving toilet flushers


• Develop creative scheduling that promotes decreased medical waste


• Do procedures with the lights off (joke)

A green medical practice.

The IU.

Some Mistakes I've Made

Mistakes are part of life and cannot be avoided. As my grandfather, Pop Pop, used to say with his thick Russian accent, "Vichie, my mistake column is longer than my good decision column." Here are some mistakes I made over the last 18 months.

• Makler Chamber: These are counting devices for semen analysis. $500 bucks each. Too labor intensive with regards to cleaning. I haven't used them in over 1 year.
  
• Olympus Cx41 microscope: reticle counting grid compatibility issues with microcell counting chambers. Better to have gone with scopes used by RSofNY.
  
• Overhead light source/OR light: waste of money $1200. Should have gone with a $50 lamp from Bed Bath & Beyond.
  
• Bayer Automated Urine Anlayzer: $800 with 2 bottles of Multistix Pro dipsticks. Bad investment. Multistix Pro not reimbursed at higher level, except by M'Care. Lost money.
• Phone system: $3000. On retrospect, still don't need it and could have gone cheaper with Cisco VOIP phones.
• Cidex trays: Used for disinfection. $300+ dollars. Really glorified plastic trays. I don't know that I could not have just gone tupperware for much less.

And other still in progress and yet to be discovered. I will say before I go, however, that at the time, those purchases were well thought out and good intentioned, they just turned out to be wrong.
Hey, at least I didn't start a war by mistake!
Hope you enjoyed this post.
The IU.

My letter to Senator Clinton

Dear Senator Clinton,

Please accept my apologies in advance for interrupting you from your campaign for President of the United States with this letter, but I feel impelled to do so. I am a solo practice urologist in Long Island who sees many patients with Medicare. As you may be aware, the costs of practicing medicine in Long Island are high and proposed cuts in Medicare reimbursement would have detrimental effects on my ability to remain in business. Please vote against them so that I may continue to practice the profession that I love and to serve the people who have served our nation.

Our nation faces many challenges both domestically and abroad. Perhaps the struggles of our nation’s urologists seem petty and provincial when compared to the struggles faced by our military, our citizens without any health insurance, and our economically pinched working and middle classes. But urologists are vital members of any community. As employers and business owners, we give much back to the society that gives to us. Please vote no to Medicare cuts that would hurt urologists in general but solo urologists like me disproportionately.

Again, please accept my apologies for interrupting you on your campaign trail and I wish you the best of luck in the race. I certainly have been and will continue to be a supporter of you.

Sincerely,

Richard A Schoor MD FACS

Automate, Automate, Automate

Automation is key, I've come to realize. Automation makes things go better. It allows for the staff and management to concentrate on things that require a human brain, such as judgment calls. At first glance, it may appear that a medical practice is not a great fit for automation. Certainly an auto plant lends itself better to robotic processes, but if you re-analyze your own medical practice, you can find processes that can be automated, and can thus become mindless and effortless. Here are some things that can, and should be automated.

• Data entry: Forms can be scanned with an OCR reader and the data can be extracted and imported into PM software, all with a key stroke.
• Communications management: Macro software exists that can reduce complex, redundant tasks to a simple mouse click. Items that come to my mind in this category are call forwarding, voice mail retrieval, and fax management.
• Document management: This is where an EMR really helps, but even without one the process itself can be automated, only the robot must be a person.
• Laboratory services: automated lab analyzers exist and are reasonably priced for good ROI. These devices can be run be someone with only a high school degree.
• History taking: forms, whether they are digital or paper, can assist in data capture that is consistent, accurate, and efficient. Patients can complete the forms themselves or with assistance from doctor or staff. Forms can be automatically imported into the EMR with a simple mouse click.
• Back-up: of course
  
• Billing: charge codes (ICD-9 and CPT) can be captured directly from the digital encounter form and can then be exported automatically into the PM software to be submitted electronically and effortlessly to the clearance house.
• Bill pay and EOB-check depositing are all ripe processes for automation.
• Payroll, a no brainer
• Savings: automated, continuous forced savings. Slow and steady wins the race.

And probably others.
Thanks for listening,
The IU.

On getting paid.

Occasionally patients just don't want to pay. Insured patients don't want to pay the co-pays. Self-pays don't wish to pay anything. "Why should I pay, you only talked to me." I don't understand this. As professionals, we make our money by dispensing advice, ie by talking.

It can be difficult to convince get someone to pay you. We are doctors after all, and people can tug at our heartstrings so that we "do the right thing." They'll give us all sorts of sob stories, and your staff will wish to waive your fees or to "bill them later." Resist this temptation. You have bills and obligations and are in no position to waive anything. If staff wishes to lower fees for a particular patient, they can take it out of their own salary rather than yours. Just my opinion. Here is how to minimize getting stiffed from patients.

• Take credit cards
• Have pay plans through outside companies (eg CareCredit)
  
• Get the co-pay before the the patient is seen
• Unable to verify coverage equals no coverage equals money up front
• Unsure of benefits equals no coverage equals money up front
• Don't be afraid to play hardball, which includes collections and litigation

Thanks,
The IU.