An Answer To Inoperability

Is Your Practice Prepared For The Upcoming World of Blockchaining?

The past several months, Blockchain technology has been making headlines everywhere. If you’ve recently attended any tech event there is a significant probability that you came out of them having heard just that bit more about it. Everybody is talking about blockchain--from the President Trump to the government of Estonia! Despite all the hype, for many people (across different industries) the blockchain concept still seems difficult to grasp, which makes it one of the most misunderstood technologies of 2017. The confusion around blockchain can be attributed both to its contentious origin (Satoshi Nakamoto, the “unknown” who designed Bitcoin and its original reference implementation) and equally to the absence of any clear and standard definition of blockchain technology. Nevertheless, the perceived (if not yet fully understood) disruptive nature of blockchain and its possible impact on business across industries makes it crucial first to understand blockchain and then to distinguish the hype from reality. Here, I’m going to attempt to unpack blockchain at a basic level and understand its implications for the healthcare industry.

What is blockchain technology, and how can we separate hype from reality?

So what is blockchain? Let’s begin by filtering out all the hype and technological jargon, blockchain technology is, at its simplest, a distributed and immutable (write once and read only) record of digital events that is shared peer to peer between different parties (networked database systems). In short, the fundamental strengths of a blockchain system are found in its data integrity and networked immutability. That said, there is always scope to build application layers atop a blockchain system and enable additional functionalities such as public or private keys, or self-executing mechanics (e.g. smart contracts), but this isn't the core functionality of blockchain technology.

To put it even more simply, let’s travel back to the 1990s, when “internet” was the buzzword. People misunderstood the internet with a tunnel vision around its early use cases (e.g. internet = email, or internet = Web). Likewise, today’s confusion around blockchain technology is not because of its fundamental properties at the protocol layer, but rather because of hype around as-yet-unproven use cases at the application level, which are often mistaken for the integral part of core blockchain technology. Today, an example would be that many people commonly identify blockchain with Bitcoin, far and away the most commonly known implementation of blockchain technology. But in fact Bitcoin is only the tip of the iceberg of several hundred applications using the blockchain system today.

Translating this analogy for the healthcare industry, the concept of blockchain technology and systems is undoubtedly disruptive, but it will not act as an end-all, be-all to solve emerging business problems in the fast-changing and highly interconnected digital health ecosystem. Rather, it will be an evolutionary journey for blockchain-based healthcare systems or applications, where trust and governance within a blockchain network or consortium will be the critical success factors for implementation.What are the most promising blockchain-based use cases for the healthcare industry?

Beyond blockchain technology’s utopian moment in the fintech industry, in the healthcare industry it has just started to inspire both relatively easily achievable and more speculative potential applications. Healthcare authorities, governments and the provider community globally (Yes, you physicians and dentists) are equally excited about the new possibilities presented by blockchain. Nevertheless, the industry needs to focus on establishing blockchain consortia to foster ecosystem partnerships and create standards or frameworks for future implementation on a large scale across healthcare use cases. The Hyperledger Foundation, an open-source global collaborative effort created to advance cross-industry blockchain technologies, is one of the best examples among many developing small blockchain consortia models in the healthcare space.

Despite the current euphoria, it’s important to understand and decode the hype cycle for blockchain technology and its realistic healthcare applications. By doing so, we believe that, among several hundred use cases, the five blockchain-based healthcare use cases mentioned below demonstrate more convincing opportunities, albeit at varying degrees of adoption across countries and health systems.

Clinical Health Data Exchange and Interoperability: 

When we talk about blockchain and healthcare, data exchange is typically the first topic to come up. Blockchain-enabled health IT systems that can provide technological solutions to many challenges, including health data interoperability, integrity and security, portable user-owned data and other areas. Most fundamentally, blockchain could enable data exchange systems that are cryptographically secured and irrevocable. This would enable seamless access to historic and real-time patient data, while eliminating the burden and cost of data reconciliation. The recent collaboration between Guardtime, the data-centric security company, and the Estonian eHealth Foundation to secure the health records of one million Estonian citizens using its proprietary Keyless Signature Infrastructure (KSI) is a classic example of blockchain technology. However, considering the complexities around data ownership and governance structure for health data exchange between public and private entities, it would be difficult to replicate the Estonian blockchain-secured health records model globally.

Claims Adjudication and Billing Management: 

An estimated 5-10% of healthcare costs are fraudulent, resulting from excessive billing or billing for non-performed services. For example, in the United States alone, Medicare fraud caused around $30 million in losses in 2016. Blockchain-based systems can provide realistic solutions for minimizing these medical billing-related frauds. By automating the majority of claim adjudication and payment processing activities, blockchain systems could help to eliminate the need for intermediaries and reduce the administrative costs and time for providers and payers. Blockchain could also have significant ramifications for improving some of the huge logistical information tracking hurdles of reliability-centered maintenance (RCM) functions. Recently, CMS announced interest in utilizing blockchain technology in place of the standardized TPE to perform beta “probes” into the fairly new field of dental sleep medicine to develop blockchain-based healthcare claims management solutions.

Drug Supply Chain Integrity and Provenance: 

Based on industry estimates, pharmaceutical companies incur an estimated annual loss of $200 billion due to counterfeit drugs globally. About 30% of drugs sold in developing countries are considered to be counterfeits. A blockchain-based system could ensure a chain-of-custody log, tracking each step of the supply chain at the individual drug/product level. Furthermore, add-on functionalities such as private keys and smart contracts could help build in proof of ownership of the drug source at any point in the supply chain and manage the contracts between different parties. For example, a company called iSolve LCC is currently working with multiple pharma/biopharma companies to implement its Advanced Digital Ledger Technology (ADLT) blockchain solutions to help manage drug supply chain integrity.

Pharma Clinical Trials and Population Health Research: 

It is estimated that 50% of clinical trials go unreported, and investigators often fail to share their study results (e.g. nearly 90% of trials on lack results). This creates crucial safety issues for patients and knowledge gaps for healthcare stakeholders and health policymakers. Blockchain-enabled, time-stamped immutable records of clinical trials, protocols and results could potentially address the issues of outcome switching, data snooping and selective reporting, thereby reducing the incidence of fraud and error in clinical trial records. Further, blockchain-based systems could help drive unprecedented collaboration between participants and researchers around innovation in medical research in fields like precision medicine and population health management.

Cyber Security and Healthcare IoT: 

According to the Protenus Breach Barometer report, there were a total of 450 health data breaches in 2016, affecting over 27 million patients. About 43% of these breaches were insider-caused and 27% due to hacking and ransomware. With the current growth of connected health devices, it will be very challenging for existing Health IT infrastructure and architecture to support the evolving IoMT (Internet of Medical Things) ecosystems. By 2020, an estimated 20-30 billion healthcare IoT connected devices will be used globally. Blockchain-enabled solutions have the potential to bridge the gaps of device data interoperability while ensuring security, privacy and reliability around IoMT use cases. Companies such as Telstra (user biometrics and smart homes), IBM (cognitive Internet of Things) and Tierion (industrial medical device preventive maintenance) are actively working around these use cases.

If you would like more insights on blockchain in the healthcare industry #weshouldtalk

And The Unexpected Cost of Health

Avoiding The High-Cost of Healthcare

Many patients these days believe that if they have health insurance, most or all of their medical expenses will be covered by their health insurance plan. But, in today’s sophisticated health insurance plans, patients are finding out-of-pocket costs are really beginning to add up, whether it be a co-pay or a portion of a medical bill that is not covered by insurance.

Consumers should begin reviewing medical bills closely…extra or incorrect charges are becoming more commonplace. In fact, Consumer Reports noted that one-third of privately insured patients have received these types of bills. And 53 percent said the situation was not resolved to their satisfaction

Calling your doctor’s office to ask if he or she is covered under your insurance is not enough. A doctor might participate with your insurance for some things (products), but not others,” Additionally, some doctor/dentists may suggest that they “Participate” with your insurance company, but this does not always mean they are an “In-network” provider!

Never rely on physician/dentist website when checking whether a doctor is in or out of network. Websites are frequently out of date…some websites are better than others. There is no national standard of what each should look like.

In an effort to conserve time and save money, patients should feel free to pepper doctors with a list of questions before starting any treatment…“Is this procedure or test really necessary?” “What are the alternatives?” “Can we wait and see?” “Are there other ways to treat this?”

To really collaborate with your physician/dentist, you should state your preference and express your feelings. Don’t be intimidated by the white coat!

One out of three consumers has received a “surprise medical bill” from a doctor or dentist -- and it happens more frequently than you think. Unfortunately, the health care system isn’t so transparent as to who is or is not in your network!

One of the most common surprise medical bills that patients receive is from the emergency room. You may visit a hospital that you are told is in network, but the radiologist doesn’t participate with your insurance.

There are other examples; when having surgery, the anesthesiologist is often out of network and patients routinely receive a huge bill for their surgery. Being treated for sleep apnea? Majority of dentists treating the disease are not in-network with medical insurance companies and patients are often shocked when receiving a bill approaching $6-7,000! You have to be diligent.

This all happens to a lot of people, often under the worst circumstances!

Some states, such as New York and California, have protections in place against unexpected medical bills. But others states have yet to follow suit. There are numerous horror stories about huge medical bills after routine medical procedures where the costs were never disclosed to the (patient).

Some of this is a result of cumbersome diagnostic codes and confusing paperwork. Some doctors/dentists simply don’t know ahead of time whether a specific kind of blood test is covered under a certain diagnostic code. This often leads to rejection by the insurance company, AFTER the procedure, and a surprise bill for the patient.

There are so many more regulations to meet these days, and it’s often frustrating for doctors. They often spend a considerable amount of time on administrative work when they really want…need to care for patients.

It’s becoming a problem that is leaving people frustrated with the medical system. If you have questions (on a bill), call the insurance company or your provider to find out what went wrong. Know what your deductible and your co-pay is. Many people don’t know this. If you have co-insurance, know what portion you are responsible for.

If you call the physician or dentist, ask for the billing department and make sure to get a clear understanding of why you received the charge, ask for an estimate and any insurance requirements IN WRITING. Also, double check with the insurance company and see if the billing department’s answers line up.

If your medical or dental practice has experienced the patient with an unexpected bill #weshouldtalk

A Patient and an Employee Walk Into a Courtroom

Policies Can Prevent Financial, Reputational Or Other Harm

Dental assistant, phlebotomist, hygienist, front office…any other practice employee is new on the job. They are excited and want to share their new position with their social media network. They snap a selfie or two to share the moment, then send it off to Facebook, Instagram, Twitter and Snapchat, with the click of a button, in just seconds. Problem?

Perhaps this is not a new employee. Maybe they’ve been with you quite a while, part of the “family”…through ups and downs – lately, mostly downs – had a challenging time at home last night, and are feeling a tad frustrated right about now. He/she picks up their smart phone, puts on their best “exasperated” face, snaps a selfie, and captions it with a summary of their frustrated state of mind, off it goes to the interweb. Not a problem, right!?

How about this… end of another great day at work. Back office had a great day of production, met a team goal, and bonus is on the horizon. “Let’s all huddle together for a group photo and sharing the love with a few thousand of our best friends online”!? More “likes”, “follows” on our Insta and Facebook page(s)! So much awesome!

Okay…pump the brakes…

Now, let’s think about…HIPAA

On its own, a work selfie may amount to bad judgment and a violation of your company’s cell phone policy.

But, what if there happens to be protected health information in the background…a patient in the operatory? Is there a open nurse kiosk screen in the background? What about a patient’s name placard on a door? Or a rounding white board with patient status or surgery information? When your employees are excited or frustrated, are they more or less likely to notice these items as HIPAA hazards?

Privacy Concerns

HIPAA isn’t the only risk. Selfies that incorporate patients can violate privacy laws. Also, in nursing facilities, CMS considers photos or videos of residents that are demeaning or humiliating to be abuse. While it is less likely and more extreme for selfies to include abusive context (which typically require intentional conduct), it DOES happen, more than you might think!

In July 2016, a paramedic team was arrested and faced criminal charges after they engaged in a selfie “war” by text. They competed to take the most shocking pictures of themselves with patients in compromising positions. We’ve all seen this on You Tube, Facebook, etc.

Now…what you can do?

Confronting the force of social media can seem taunting, but providers have had great success with social media compliance culture campaigns.  Employees must understand that their phone might be their personal property, but HIPAA privacy laws and abuse laws apply when they use it at work.

Staff needs to be mindful of their surroundings and background if they are using their phones at work (and, of course, if this is permitted under your policies). Remind them that taking, with some very limited exceptions, a picture of a patient is never okay – even if the patient is in the background. This sounds obvious, but countless employees have made headlines by inadvertently making this mistake. Additionally, even taking a picture with the patient’s “Sure” as an approval can get you in hot water!! You MUST always…ALWAYS secure and retain a patient’s WRITTEN release to post ANY images with their likeness!

Educate employees and create a policy that informs your entire staff that inappropriate photos can violate privacy laws, constitute abuse, and lead to license discipline, criminal charges and lawsuits. Make sure they understand what’s at risk!

Finally, make the message pervasive. Not just at hire and once a year. ProPublica has posted 65 examples of inappropriate social media posts by nursing home staff since 2017. In many of the examples, the home had a social media policy. Social media use is rampant. Your social media compliance campaign should be, too!

If your medical/dental practice hasn’t created a social media/HIPAA compliance policy #weshouldtalk

Mitigating Stark Law and AKS Exposure

Protocol Development Can Prove Invaluable

Did you know that a dentist "renting" medical diagnostic sleep testing equipment then paying the entity who owns the equipment for patient testing constitutes fee splitting!? Or, paying for patient referrals can fall under both kick-back and Stark Law!?  

When making business arrangements between a medical or dental provider or an agency and another party, liability issues can get pretty janky, pretty quickly. Common-knowledge laws that affect most healthcare providers and their practices are Stark Law (physician self-referral) and the Federal Anti-Kickback Statutes (fee-splitting). Since both of these laws are Federal, they govern most situations wherein there is federal money involved as reimbursement, specifically, Medicare or Medicaid.

That said, 37 states, including California, have enacted their own particular laws that govern self-referrals and fee splitting. Many times the state law(s) may even be more strict than that of the Federal law, as is the case of California.

Since this is not intended to be a definitive guide on fee-splitting or kickbacks we will not discuss "safe harbors" that could protect the interests of providers. However, hopefully we can provide a broad-brush, quick overview of main California law(s) and some guidelines on how to avoid falling outside State regulatory guidelines.

California Fee-Splitting and Anti-Kickback Laws

Most notable is California Business & Professions Code Section 650 (B&P 650) and is the law that largely governs in the State of California fee-splitting and kickback practices for healthcare practitioners.

California B&P 650 reads as follows:

“(a) …the offer, delivery, receipt, or acceptance by any person licensed under this division or the Chiropractic Initiative Act of any rebate, refund, commission, preference, patronage dividend, discount, or other consideration, whether in the form of money or otherwise, as compensation or inducement for referring patients, clients, or customers to any person, irrespective of any membership, proprietary interest, or co-ownership in or with any person to whom these patients, clients, or customers are referred is unlawful.

(b) The payment or receipt of consideration for services other than the referral of patients which is based on a percentage of gross revenue or similar type of contractual arrangement shall not be unlawful if the consideration is commensurate with the value of the services furnished or with the fair rental value of any premises or equipment leased or provided by the recipient to the payer. “

This is California’s version of the Anti-Kickback statute, and is tougher than the Federal equivalents because not only does it cover reimbursements from Medicare and Medi-Cal (California’s Medicaid), but it also covers any reimbursements or transactions from private health insurance and Workers Compensation.

The next law to be aware of is California Health & Safety Code Section 445 (H&S 445) which covers medical referrals:

“No person, firm, partnership, association or corporation, or agent or employee thereof, shall for profit refer or recommend a person to a physician, hospital, health-related facility, or dispensary for any form of medical care or treatment of any ailment or physical condition.”

So, it’s pretty clear that California does not tolerate any referrals given or made from inducements of any kind.

The Corporate Practice of Medicine

There is a doctrine known as the Corporate Practice of Medicine, where non-physicians employ physicians specifically to practice medicine. The theoretical danger is that the corporation can put pressure on the physician to make decisions about patient care that are not in the best interests of the patient, but rather in the interest of making money for the corporation.

This concept is prohibited in California with California Corporations Code, Section 13408.5:

“No professional corporation may be formed so as to cause any violation of law, or any applicable rules and regulations, relating to fee splitting, kickbacks, or other similar practices by physicians and surgeons or psychologists, including, but not limited to, Section 650 or subdivision (e) of Section 2960 of the Business and Professions Code. A violation of any such provisions shall be grounds for the suspension or revocation of the certificate of registration of the professional corporation. The Commissioner of Corporations or the Director of the Department of Managed Health Care may refer any suspected violation of such provisions to the governmental agency regulating the profession in which the corporation is, or proposes to be engaged.”

Broad Guidelines to Remain In Bounds of the Law

While it may seem tricky to make a business arraignment as a healthcare provider, there are a few some simple guidelines that can keep you on the road to legal compliance and create a structure that can be justifiable to state regulator scrutiny.

1. Be certain that whatever fees for services that are negotiated and contracted in an agreement for services with a third party are:

Fair market value.

(1) This cannot be emphasized enough! You must seriously consider having in your contract a statement that says for x many injections, you get y $, or for x many hours, you get y $ per hour, or for x many months you get y $ pay and the dollar amounts are largely similar to the same fees of the area that the agency is geographically situated in.

Also, be certain that your contract clearly says that there is no control or undue influence over a physician when it comes to treatment of patients from another party. This includes proprietary interests by a physician into another agency or service they are referring patients to and vice-versa.


While the subjects of fair market value, inducements, Corporate Practice of Medicine, self-referrals, and fee-splitting are vast and can be discussed in volumes, this article was meant to be a very brief introduction to the laws of California fee-splitting and referrals. If you have questions about your arrangements, a smart and capable healthcare attorney should look over whatever contracts you make so that you don’t violate Federal or State laws and to ensure you are able to structure your contracts to fit within a "safe harbor" that protects your interests.

Other California Anti-Kickback and Fee-splitting Laws

California Business & Professions Code, Section 2273(a) states:

“Except as otherwise allowed by law, the employment of runners, cappers, steerers, or other persons to procure patients constitutes unprofessional conduct.”

California Health & Safety Section 445 (“Medical Referral Services”), states:

“No person, firm, partnership, association or corporation, or agent or employee thereof, shall for profit refer or recommend a person to a physician, hospital, health-related facility, or dispensary for any form of medical care or treatment of any ailment or physical condition.”

California Welfare and Institutions Code Section 14107.2:

Prohibits kickbacks in the context of public health services such as Medicaid and Medi-Cal.

In contrast, Section 14107.2 provides that the prohibitions in 14107.2(a) do not apply to:

“Any amount paid by an employer to an employee, who has a bona fide relationship with that employer, for employment with provision of covered items or services.”

If you need assistance minimizing your Stark Law or AKS exposure #weshouldtalk 

Bursting The Management Bubble

Intelligent Management Can Optimize Your Practice

Practice managers and administrators play an integral role in medical and dental practices. If provided with adequate resources, training, and educational opportunities, they can manage the business of care delivery — allowing their doctors and dentists to devote their time to patient care.

Here are 10 things every physician and dentist should know about these important individuals:

1. Practice managers and administrators wear many hats. They are experts in operations management, financial management, human resources management, organizational governance, risk and compliance management, and patient-centered care. Physicians can be confident that they are highly competent and efficient, and experts in medical/dental practice management. Employing a versatile and knowledgeable practice manager will position your organization for success.

2. Practice managers and administrators should pursue board certification in medical practice management. Board certification in practice management helps to validate that practice managers have the knowledge and skills to excel in a practice. Credentials in medical and dental practice management include CMPE, AADOM and FACMPE. If your managers do not have these credentials, provide them with opportunities and resources to pursue them.

3. Practice managers and administrators are playing an increasingly important role in serving patients. Managing a medical or dental practice involves cultivating a team of sophisticated and knowledgeable staff that ensures patients have a positive experience when they visit the office.

4. Practice managers and administrators can help guide collaborations with other healthcare stakeholders. There are many new ways providers and organizations are formally and informally collaborating and integrating. Practice managers can evaluate options, and strategically guide alignments that will benefit your practice. Physicians and dentists can be assured that practice managers have the tools and resources they need to understand and evaluate these opportunities, through education and networking that is facilitated by their professional memberships.  

5. Practice managers and administrators can help practices improve care quality while reducing costs. Managers can use EHRs to identify and group patients with chronic diseases and/or conditions, such as diabetes or periodontal disease. This can help practices better tailor their treatment approaches and target various patient populations. Providers should ensure that their managers have adequate training to use the software and tools available to them within their practices.

6. Practice managers and administrators navigate the complex regulatory environment. There are a plethora of federal regulations that practices need to be aware of and adhere to and practice managers can ensure groups remain in compliance and keep up-to-date with the evolving regulatory environment. Setting aside time for practice managers to learn about and understand applicable regulations will help to minimize your practice’s risk in the long run

7. Practice managers and administrators can implement and optimize technology that drives better patient outcomes and guarantees efficient practice operations. Managers can lead the charge in implementing EHRs and practice management systems, as well as other technology solutions that help patients, such as portals that are designed to engage patients in their care. Physicians/dentists and practice managers should collaborate to understand the technology needs of the organization, then to ensure that it’s operationalized thoughtfully. Additionally, be sure that staff are trained to input and access data accurately. 

8. Practice managers and administrators know their data. In addition to understanding and monitoring the many metrics that payers require, practice managers can use data to benchmark their organizations against their peers. They can use industry data to develop provider compensation plans, monitor the cost of running a medical/dental group, and assess how to best staff their practice. A benefit to setting aside time to participate in industry surveys is then accessing the survey data for free, which gives your practice up-to-date, relevant information.

9. Practice managers and administrators ensure patients have access to prompt, appropriate levels of care and manage cases between facilities.

10. Practice managers and administrators help providers devote their time to patient care. Because practice managers are experts in the business of care delivery, they can run an efficient practice, allowing physicians and dentists to devote 100 percent of their time to patients. In trusting and teaming with your practice staff, providers can spend their time visiting with and caring for patients, with assurance that practice operations are being run smoothly, efficiently, and effectively to position your practice for long-term success and sustainability.

Is your practice in capable hands? #weshouldtalk

More Than Just Splitting Hairs

Is Your Dental Office Paying For Patients?

In today's economic climate, costs are increasing, reimbursements are decreasing and although physicians and dental professionals are working harder, they're making less money.

In battling this inverse relationship, medical and dental professionals are seeking ways to enhance income. One temptation is referral arrangements, whereby a physician, dentist or lab/service provider is paid or pays another physician or dentist for patient referrals.

While this practice may be standard in other industries, it may be illegal "fee splitting" in the health care industry. Beware that such referral relationships may not be only a breach of ethical and professional standards, but also a violation of federal and state laws.

The American Medical Association and American Dental Association’s Code of Ethics provides that a "payment by or to a physician/dentist solely for the referral of a patient is fee splitting and is unethical." A physician/dentist is thought to engage in fee splitting when he or she divides a patient fee with a recommending physician/dentist. For example, a sleep physician and a dentist may have an arrangement whereby the dentist shares part of his or her fee by way of paying a “referral fee” with the sleep physician who referred the patient.

Similarly, the American College of Physicians Ethics Manual states, "a fee paid to one physician by another for the referral of a patient, historically known as fee splitting, is unethical."

The AMA's Code of Medical Ethics goes even further and mandates that "a physician may not accept payment of any kind, in any form, from any source ... for ... referring a patient to said source."

"Anti-referral laws" is a phrase commonly used to describe the collection of federal and state fraud and abuse laws that regulate physician referral arrangements. These laws not only invalidate referral agreements, but more importantly, may subject physicians and dentists to monetary fines, imprisonment, license revocation and other disciplinary actions.

Federal regulations

At the federal level, the anti-kickback statute and the Stark law heavily regulate physician referrals.

The anti-kickback statute explicitly states that it is a felony to solicit, receive, offer or pay anything of value, directly or indirectly, overtly or covertly, in cash or in kind, in return for referring patients or services for which payment is made by a federal health care program, such as Medicare or Medicaid.

The law punishes both sides of the deal, the referring and referred physicians. While the statute applies nominally to federal health care programs (thus patients or services not covered by these federal programs are outside the purview of the statute), the Stark law and/or state law may nevertheless prohibit the arrangement.

Under Stark, a physician may not refer Medicare or Medicaid patients for designated health services to an entity with which the referring physician (or his or her immediate family member) has a financial relationship, subject to some exceptions.

State prohibitions

At the state level, each state maintains its own position with regard to fee-splitting and physician referral agreements. Often, states create regulations that are enforced by the state's attorney general and which are applicable beyond just state funded programs/patients.

In Colorado, for example, a fee-splitting prohibition is contained in a subsection of the Colorado Medical Practice Act that subjects a physician to potential discipline for "dividing with anyone other than physicians with whom the licensee practices in a partnership, professional association, limited liability company, or medical or professional corporation any fee, commission, rebate or other form of compensation for any professional services not actually and personally rendered."

Steer away from the temptation

The key policy supporting the widespread prohibition of referral agreements and fee splitting is the notion that it creates a conflict of interest for the physician/dentist.

As the AMA's Code of Ethics states, a referral from a physician should be the product of the patient's needs and the referred physician's reputation, training and skill -- not the basis of an economic arrangement that could undermine patient trust.

Even the appearance of impropriety can compromise the patient's trust for both physicians/dentists involved and ultimately can undermine the public's confidence in the medical/dental profession. Currently, in Colorado, at least 12 dentists and a sleep physician are being investigated by the Dental Board, Medical Board, Attorney General and Office of Inspector General for a relationship that may constitute numerous state and federal regulatory violations.

When money is tight, human nature often allows otherwise prudent businessmen and women to make financial mistakes. Don't change your practice pattern to include suspect procedures simply to enhance short-term financial relief.

If you are unclear as to the legal ramifications of your exposure #weshouldtalk

Wild West Dental Sleep Medicine

Is Wild West Dental Sleep Medicine About To Be Wrangled In?

Is Wild West Dental Sleep Medicine about to be wrangled in?

In recent years, with all the dentists dipping their toes into the dental sleep arena, it seems there is becoming a shift in the idea of what exactly the dentist's role is, or should be. Should they test...should they diagnose, and on and on.

While it all seems so exciting, one fact that seems to be escaping us most is're a DME! If, in all this excitement, you lose direction, here's a reminder!

While this may not sit well with some of you, in the world of dental sleep medicine, that's your role as a dentist! With all the recent pontification about residencies, exhaustive training, years of experience, she was previously owned by a little old lady in all still boils down to one thing; your job as a dentist is to fabricate the appliance! And, why not? I mean, our dental clients love the idea that they are tasked with creating the appliance, billing insurance and allowing the medical doctor to assume the role of treating physician! Are you being restricted financially?? Well, Endeavor Health has a dental client in California who has CONSISTENTLY delivered over one-hundred appliances per month, for the past five plus years, at an average of $3,200 each!

We routinely see dentists promoting their voodoo medicine...supine CBCT to look at the airway, rhinometry to view the dimensional aspect of the airway. WOW!!! That all seems so fancy, "Stu"! But fact is, that's all useless data, for a few reasons!

First, if one wishes to needlessly expose the patient to the radiation of a CBCT to view the airway...well, that looks really great when the patient lays back on the dentist's shiny new $250k New Tom 5G Supine CBCT. BUT...that data is useless for this diagnosis!! And, when the dentist pulls out his/her acoustic rhinometer (Even in the hands of a qualified medical doctor, this is experimental when it comes to most all health insurance companies, btw) and starts probing the patient..."WOW, that's high-tech equipment!!! But, again...useless data!!!

The challenge here...there is one factor, one essential factor that need be present whenever PROPERLY evaluating a patient for obstructive sleep apnea. Wait for it...THE PATIENT NEEDS TO BE ASLEEP! If you doubt or question that, here is the forth grade level math you or do you know someone who snores? Does that person snore when they are awake? There you go! The easy math equation to conclude that there is in fact a change in the dimensional aspect of the airway from a state of sleep and wakefulness! You are now a dental sleep expert!!!

But, wait...there's more!! Dental Sleep Medicine really is NOT rocket science! For all the pontification about "mini-residencies" (we just recently watched a long-time practicing sleep dentist stand-up and proclaim that two cases he saw were performed by dentists who were educated by a two-day dental sleep program when, in fact, those two cases were performed by his colleague, a 30+ year local sleep dentist...everybody's an expert!), the fantastic data, the numerous conferences, seminars, CE's, certificates on the wall, YEARS of experience and the knowledge of the multitude of comorbid issues and secondary diagnosis'...RLS, Polycythemia, Retinal Vein Occlusion, Drug Resistant Hypertension, et can NOT identify, diagnose, treat, evaluate, prescribe, or even glove up!!! REMINDER

Dental Sleep Medicine is an evolving field! If you fail to evolve, you WILL become obsolete! And, there is a litany of programs designed to make you think this is the most difficult part of your practice. Fact is, it's not! It may, however,  absolutely be one of the most important, from a patient health perspective. And, we agree that, as a dentist, you should ABSOLUTELY be screening every patient who walks into your office!! When proper protocols are in place, our dental clients routinely discover things about their patients they never knew! Most common; 23-25% of their patient mix is either currently on PAP therapy or has been at one time and fallen off! But, be is a negligent dentist who suggests to a CPAP compliant patient that OAT is a better choice over the gold standard! And, for those of you who say, "My sleep physician doesn't have an 82% compliance amongst his CPAP patients...perhaps you need a new sleep doc?!

In any case, I digress! Point being, as a dentist, you are presented with groundbreaking opportunity here! For those patients shuffling thru life like The Walking Dead, on an aimless destination from point A to point B, you can be the awakening for them all (see what I did there?!)! Screen, educate and, for God's sake, get them to a physician and collaborate to provide the patient with the best treatment option(s) for their life and lifestyle! I promise the money will follow!

But, if it is your goal to pursue patients for the all-mighty dollar, to screen, test, "treat" and do it all in your office, the potential harmful ramifications WILL eventually catch up to you! And, it will likely be at the patient's expense!

For those of you who mope around with the "We live in Mayberry and there are no sleep physicians"; you are part of the problem! There are COUNTLESS IDTF organizations across the United States who will either personally deliver or drop-ship an FDA approved testing device to your patient's front door!!! And, the beauty, they will take care of the insurance verification and billing for the test, provide you a study read by a Board certified sleep physician all inside an average of five to eleven days! And, another YUGE bonus...again...wait for it...protect you from the disservice of placing your patient in financial harm's way when insurance discovers that the DME dispensed the testing equipment and the claim is denied!

Dental Sleep Medicine...there's a change a brewin'! Mount your steed! Yee Haw!

Quality vs. Value

Does "Quality" Help Patients?

Two quality metrics walk into a bar.

One demands, “Give me the best beer you’ve got!”

The other says, “Give me the second-best beer you’ve got.”

The bartender pours the beers and states, “You can have them both for free if you can tell me why this one is better than that one.”

Quality metrics were invented to quantify the ineffable, such as the taste of a fine lager or IPA. These days, we in Colorado are seeing local brews being listed in “International Bitterness Units” (IBU). Some may actually order their choice based upon this listing. At the very least, it gives us something to talk about while enjoying our beer.

Just as listing the IBU is new in beers, metrics did not always exist in medicine. The moment we became serious about quality is often cited as Dr. Philip Caper’s 1988 article “Defining Quality in Medical Care.” Even as medicine invented “quality” in the 1980s, Dr. Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and rather using three terms that correlate to desirable medical outcomes: efficacy, appropriateness and the caring function. We know that certain interventions are efficacious in certain conditions; we can measure that. We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this. And we know that patients want “caring providers.” We likely cannot measure this very well, but it may be the most important of all the factors. The “quality” of care is more than all of these factors and perhaps quite different entirely.

Despite the prescient warning, we have not abandoned “quality, ” and its continued use has created an entire jargon: quality, measurement and value. Quality creates value. We are all preoccupied with creating value now. The term is rarely defined but often used: creating value to insurers, for payers, for health systems and even for patients. It appears to have a vague but unacknowledged relation to quality.

No one used to ask whether they got value when they went to the doctor’s office. We might have discussed whether we had a good doctor but never whether the experience was valuable. When we buy a car, we sometimes wonder whether we’re getting a good deal and whether the exchange had “value”. But when we sit with friends for a beer at the pub we never ask whether we’re getting a good value out of the experience. The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor.”

Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.” Nor do we ask whether our evening at the pub was “quality time,” and rarely whether we just drank a “quality” beer. Remember “quality time” spent with our loved ones? Once we started asking this about the time with our children, it already represented an unacknowledged loss of the inherent relational component of life. Just so, once we started using “quality” and “value” in medicine, we had already lost its primary relational component. Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.

Quality itself relates to the humanistic function of medicine, and not to its scientific trappings. As such, it is describable but not measurable. As an individual patient, whether our A1C is less than 9 percent correlates only tangentially with the quality of the care our physician provides. We might do better to have a lower A1C, but the factors involved in lowering our A1C, and how we perceive the care we have received, are not measured by the A1C itself. Presumably, the A1C captures the “efficacy” of the care received. It is a gross injustice to label this as “quality.” Substituting “quality” for “efficacy” defines patients as lifeless objects rather than by their characteristics as human beings.

Pay-for-performance takes medical quality metrics to the next level by using them economically. In our health care system, they are not working to improve care — why? Because the metric does not incentivize doctors to be more human. Instead, it rewards treating patients as commodities and lifeless objects. Doctors resent this incentive because commodification is dehumanizing. As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately attempt to pull them back towards a humanistic ideal. Satisfaction itself is now a commodity and subject to the rules of the market — massive, absurd inflation everywhere!

However, what does not work on an individual level, can work on a group or institutional level. Some payors, government and private insurance reimburse hospitals (more or less) depending on how they perform on various metrics. With some exceptions, this tactic appears to overall have improved medical care in America. Companies should be held responsible or rewarded for the quality of their products. Corporations have always responded well to financial incentives — it’s why capitalism works!

The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives.” This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans. Be careful with your jargon, and be wary of individual metrics. 

If your practice is interested in providing patients with a more “value-based” experience #weshouldtalk

Are You a "Provider"?


Integrating sleep medicine into the delivery of care for most dental practices has been a challenge for dentists as well as medical professionals, payors and patients across the board! When considering the litany of difficulties the dentist faces when introducing sleep medicine into his/her practice, our recommendation is always that a multidisciplinary care delivery model is the only true successful pathway for oral appliance therapy. 

Although sleep science has advanced significantly in the last decade, the delivery of care for breathing disorders continues to remain fragmented. For the most part, oral appliances have historically been underutilized. And, while there seems to be a natural tendency to create separate “shops” for each specialty, a multidisciplinary care stressing the need to be able to play in the same “sandbox” (care-under-one-roof model) offers distinct advantages to improved patient care, continuity of treatment, and the central coordination of benefits, both insurance-related and clinical.

Past Challenges to Integrated Care

Reasons for dental sleep medicine failing to integrate fully with the delivery of sleep medicine care are many. First, the growth of dental sleep therapy has not kept pace with the exponential growth of sleep medicine in the treatment of obstructive sleep apnea (OSA). Dentists who provide appliance therapy for breathing disorders are seemingly few in number. And, many of those who do often tend to step into the world of the treating physician, further creating discord when attempting to align with a medical practitioner. The most frequently reported occurrence is when the dentist usurps the position of the medical doctor and begins participating in the diagnosis of sleep disorders.

While the dentist is well-positioned to "screen" patients for sleep - based on their time looking directly into the airway - moving into the diagnostic process quickly takes the dentist outside of their scope of practice. We know that most all private third party medical insurance payors adopt Medicare guidelines, and most haven't understood or enforced their own guidelines...until now!


Presently, dental boards in Colorado, Iowa, Nebraska, Oklahoma, Georgia and North Carolina are currently looking to adopt specific Medicare guidelines within their respective Dental Practice Act(s)...expressly prohibiting the dentist "DME" from participating in the sleep study, even as much as having the testing equipment picked-up or delivered in their office.

Development of these guidelines is the result of the numerous "programs" that encourage the dentist to diagnose sleep patients and bill cash for this service -again, outside their scope of licensure. Another example of the dentist approaching "scope" concerns would be the dentist titrating the appliance, here the jury is still out. However, the general consensus in the medical community is; the dentist "adjusting" the appliance is akin to their stepping into the "treatment" of this medical diagnosis. In fact, Medicare has recently confirmed that their designating the dentist as the "DME" is to prevent them from attempting to assume a role of "provider". 

education is key

Another limiting factor in dental sleep medicine is the lack of education in the specialized use of oral appliance therapy for sleep disordered breathing among dentists and sleep physicians. 40% of dentists know little or nothing about oral appliances for treatment of OSA. Moreover, 49 responding dental schools of the 58 US schools recently surveyed reported only 3 hours of total curriculum time devoted to sleep medicine. With the exception of short courses offered by such organizations such as AADSM, dentists have relied on training from marketing/retail groups often associated with hoping to sell specific appliances and products for sleep medicine, charging exorbitant fees for equipment for which use, the dentist is unable to receive direct insurance reimbursement - if you can't get paid, it is likely outside your scope of practice!

ever evolving

To date, the knowledge of new materials, techniques, procedures, and continuing education has been limited to dental journals, periodicals, and advertisements. Efforts are under way to formalize dental sleep medicine training in our dental schools. The University of North Carolina School of Dentistry has already hosted conferences for dental educators across the United States and Canada in conjunction with developing predoctoral DDS and clinical residency programs.

collaboration rather than competition

Education to sleep physicians and technologists about oral appliances has been virtually nonexistent. Indeed, there have been recent efforts to train physicians to practice oral appliance therapy at professional meetings. Although this practice raises awareness of oral appliance therapy, it can undermine recognition of the training dental sleep experts undergo to properly evaluate the integrity of the teeth, the surrounding bone, and temporomandibular joints; to obtain accurate impressions and fit removable oral appliances (such as dentures and bite guards) to the teeth; and to minimize negative side effects of their presence.

Most importantly, communications between sleep physicians and dentists have been suboptimal in most healthcare settings. Even in academic settings, interactions between medical and dental professionals have been limited by their separate and different clinics, patient record systems, administrative priorities, and business models. There has been little need to co-treat patients in the past; thus the infrastructure and administrative support to encourage good communication between medical and dental sleep providers are lacking.

The co-treatment of patients with dental clinicians has been viewed as vaguely competitive to some physicians who provide CPAP as the primary treatment modality. This is directly correlated to the dentist assuming the role of provider, which more often than not limits referral of patients for oral appliance therapy. However, a truly successful relationship between physicians and dentists can only be established by close communication and sharing the common goal of patient centered treatment.

reimbursement driven therapy

Routine referrals to dentists is also often discouraged by the lack of, or limited reimbursement for, oral appliances by insurance carriers. Although Medicare recognized oral appliance therapy as early as 2005 as a potential first-line therapy for mild and moderate OSA and for patients with severe OSA who fail positive airway pressure therapy, many medical insurance carriers have only recently began to provide benefits for oral appliance therapy. Progress on this front has been slow and severely challenged by claims processing centers that are not prepared administratively to negotiate contracts with, or process claims from, dentists who are treating a medical condition, dental practices that are unfamiliar with submission of medical insurance claims and the appeal process upon denial, and reduced reimbursement rates for appliances that may not meet the dentist's costs for high quality oral appliances and the chair time required for comprehensive follow-up care.

follow-up is essential 

Post-intervention care with oral appliances also has left much to be desired. Patients undergoing sleep therapy are often reluctant to return to the referring physician for follow-up evaluation of the efficacy of oral appliance therapy, often citing the costs of another sleep study or its inconvenience as reasons for their reluctance. One study revealed, only 18% of patients receiving oral appliances underwent follow-up testing after the initiation of therapy. For those patients who do return for a follow-up sleep study and for whom there is residual sleep disordered breathing, another sleep study with yet further costs and inconvenience may be indicated after adjustment of the appliance.

evidence-based therapy

With the lack of these necessary follow-up tests, outcome measures are not been well documented for oral appliance therapy. While some controlled trials have shown improvement in daytime sleepiness and blood pressure on a short-term basis, the impact of oral appliances on cardiovascular disease on a longterm basis remains largely unknown. Such data on robust outcomes measures are needed to substantiate the long-term benefit of oral appliance therapy when compared to those of nightly use of positive airway pressure.

These outcome measures form the backbone of the proposed model's care of patients with obstructive sleep apnea. Outcome measures would serve as benchmarks for quality assurance and improve our understanding of the natural history of the disease with different interventions. Several outcome measures would be evaluated for quality assurance including compliance (patient-reported until reliable low-cost objective measures can be obtained), post intervention reductions in the AHI and excessive daytime sleepiness (e.g., Epworth Sleepiness Scale) and improvements in scales of neurocognitive functioning (e.g., psychomotor vigilance testing). Recently, mouth temperature-sensing compliance-monitoring chips embedded in oral appliances have been shown to be useful in recording hours per night and nights per week of therapy. This technology provides oral appliance data similar to compliance monitoring of positive airway pressure therapy. Long-term followup and monitoring of blood pressure, cardiac and cerebrovascular events, and mortality should be undertaken, so that the benefits of oral appliance and positive airway pressure therapies can be compared. A concomitant surveillance of adverse effects (both short-term and long-term) should be documented.

enter the provider

Safety and compliance monitoring should be conducted by a Board certified sleep physician every 4-6 weeks after an appliance is delivered until treatment efficacy and patient adherence have been established. The importance of this monitoring being performed by a physician is not only to ensure compliance, but only the physician can evaluate and address any patient adverse effects. Noncompliance (compliance being defined as ≥ 4 h use for ≥ 70% the nights) or failure due to intolerance of oral appliance therapy would trigger an alternative treatment strategy ordered only by the sleep physician. Some alternatives might include hybrid therapy, PAP therapy, or surgical intervention in select cases. A sleep specialist would manage any concomitant sleep disorders, which a patient may have to avoid overlap of visits. Cardiovascular and cognitive markers would be recorded for outcome data analysis and quality control.

In the end, there are specific Medical and Dental Licensing Laws and Practice Acts, which dictate the scope of practice for physicians and dentists  As per individual state law, laws only a licensed physician can make a diagnosis and treatment plan for sleep disordered breathing. Similarly, a dentist's scope of practice includes, and is limited to evaluating the candidacy of patients for oral appliance therapy as well as construction and fitting of the appliances. If the “care-under-one-roof model” is considered, comprehensive care can be performed within the practice parameters established by the CMS guidelines. Additionally, updated practice parameters are currently being prepared by the AASM for publication.

Responsibilities of sleep physician specialist:

  1. Assess patients with sleep related complaints.

  2. Order appropriate diagnostic tests and diagnose obstructive sleep apnea.

  3. Discuss treatment options with the patient based on practice parameters and standard of care guidelines.

  4. Counsel on behavioral therapy, sleep hygiene, weight loss, and driving precautions.

  5. Manage concomitant sleep disorders which often accompany OSA, such as restless legs syndrome (RLS)/periodic limb movement disorder (PLMD), circadian rhythm disorders, and insomnia.

  6. Follow and document comorbid conditions and impact of treatment on hypertension, diabetes, heart failure, arrhythmia, and neurocognitive function.

  7. Engage in active consultation with staff dental sleep expert on treatment plan.

  8. Participate in periodic multidisciplinary rounds and conferences.

  9. Provide follow-up sleep testing after OSA therapy has been instituted.

  10. Provide ongoing and routine follow-up patient care.

  11. Review compliance and manage potential complications or adverse effects of therapy.

Responsibilities of staff dental sleep expert:

  1. Evaluate patients for dental sleep medicine therapies.

  2. Discuss treatment options (mandibular advancement splints, combination MAS/PAP therapy, tongue retaining device, maxillofacial surgery, etc.).

  3. Manage coexistent dental disorders, such as bruxism.

  4. Counsel on dental hygiene and daily maintenance of oral appliances.

  5. Maintain communication with sleep physician specialist for outcome measures monitoring.

  6. Participate in periodic multidisciplinary rounds and conferences.

  7. Provide ongoing and routine patient followup care.

successful treatment is the only success

Integrating oral appliance therapy into the delivery of care for obstructive sleep apnea syndrome has been a challenge and few effective models exist so far. It is imperative that the sleep medicine community develops a realistic and effective model of this underutilized but promising treatment modality. The best structure is to integrate dental sleep medicine with the sleep disorders program is via a care-under-one-roof concept. Training, communication, education, marketing, and evaluating outcome data are vital. Such centers of excellence at academic institutions are best suited to lay this foundation. These institutional centers can provide care in their community as well as serve as a model of integrated care delivery for sleep medicine throughout the country in non-academically based sleep centers.

Thinking of integrating a successful dental sleep program into your practice #weshouldtalk

Reasons To And To Not

As Endeavor Health is a management consulting firm, the title of this blog post may not appear too shocking, but let’s be fair and start off with why not to hire a consultant.

Consultants aren’t magicians. You shouldn’t seek a consultant if your product or service doesn’t make sense. You shouldn't expect a consultant to swoop in and secure more patients if you don’t have a methodology that allows you to stand out. And finally, don’t hire a consultant so you can abdicate the all-important role of marketing to an “expert.”

A truly great consultant won’t accept your money unless they believe they can actually help you and, no matter what you believe your burning need is, a competent consultant should always evaluate the client before considering engaging in the relationship. 

Here are just a few areas that should be considered by a prospective consultant:

You need a real strategy

A great consultant will demand that you spend time building a firm foundation based on strategy before proposing a series of tactics aimed at lifting patient numbers. Until you’ve found fa way to change the context of how your ideal patient views your practice, in effect rendering the competition irrelevant, you’ll find that your marketing efforts will never build momentum.

You need fewer objectives

A great consultant will help you determine your highest payoff work and your most pressing objectives based on where you want to be in a year, in three years, in five years – not next week. And, a great consultant will make sure that the number of priority objectives at any given time stays very, very small.

You have resource gaps

Sometimes in the “do it all yourself” world of a single provider practice it’s difficult to spot the areas that require outside help. You may be able to set up your newsletter, add plugins to WordPress and clumsily create header graphics for your social media profiles, but is this work actually robbing you from focus on higher payoff work.

Sure, some of these things may need to be attended to, but a great consultant will help you stop doing the things that are better handled by others. In fact, they might just help you once again take control of your practice.

You need to fix your conversion

This may be our favorite!? Too many medical and dental practice owners, and sadly some “consultants”, focus on traffic and likes when the highest priority should be conversion. When you can figure out how to get prospective patients to your website and those prospects then respond to your presentation by making appointments you can build a significant and successful practice!

Once you have conversion trending upwards you can then buy traffic confident in the fact that you can bank on conversions.

You can’t stay focused

One of the dirty little secrets of consulting is that a significant part of you simply needs someone to hold you accountable – someone to help you document your goals and objectives and then whack you with some sort of a stick when you wander off into new ideas and social networks, because staying focused seems way too boring.

A part of this is accomplished through constant review(s) and monitoring and hard appointments, but the greatest gains are achieved when your focus starts to produce results! A great consultant will demand metrics tied to objectives and help you process and understand to overarching value you’ll derive by hitting your goals.

Okay, now you can go and check email and play around on Facebook for a bit, but tomorrow it’s back to rocking practice goals! #weshouldtalk.

Sustaining Momentum During Sleep Integration

Five Behaviors Can Keep Bad Habits From Reasserting Themselves

In recent years, dental practitioners in North America have begun realize that status quo earnings have placed the financial health of their practice at risk. Office staff have become restive, and the principals are pushing to set a new growth trajectories. The introduction of sleep medicine presents a logical and determined way to embark on what often proves to be a Herculean and seemingly successful effort to create business within the practice. In the average dental sleep practice, earnings before interest, taxes, depreciation, and amortization (EBITDA) often increase by more than $600k annually, significantly improving cash position of the depressed dental office.

The story can be a salutary one for any practice failing to embrace proper introduction and integration of any new treatment modality. But thankfully, on the face it, and by the grace of the sheer force of will, a successful sleep medicine integration will unleash the hidden potential of most general dentistries and almost always sends financial performance into a measurable upward trajectory.

However, due to the recent creation of model upon model, many tough and painful decisions must be made before most dental practices’ pull the trigger. There are a litany of “sleep consultants” offering success models that are little more than illusion. Selling and promoting use of impressive looking, high-tech equipment and providing “cash-reimbursed” diagnostic scenarios often place the dental professional in harms way. As a result, going into 2017 dental sleep medicine finds itself under close scrutiny by state, federal and private, third party insurance regulators, and charging cash will no longer protect dentists from the guidelines they are currently working to circumvent with these practice models.

Aside from operating outside of regulatory guidelines, many “sleep consultants” fail to recognize the important functions of sustaining a successful sleep medicine program, which may sound obvious—and the actions required straightforward. But they’re not. “Consultants” routinely neglect regulations with their “ways to get around guidelines” because, understandably, they’re obsessed by their short-term gains. But, equally important to operating within regulations, and key to sustaining a successful sleep medicine program is to embed an “execution engine" - replicable processes that fundamentally change performance rhythms and decision making in the practice - raising sights beyond the strategic choices and daily initiatives to change how the sleep practice functions.

Building this engine requires five distinct behaviors:

1. Take independent perspective.

Challenge everything! It can be exhausting, but a practice that can sustain change will never be satisfied with the status quo. Continually looking for fresh facts rather than accepting the status quo and constantly guard against falling back on negotiated targets that staff may accept easily.

2. View the practice like an investor.

This is not always a mind-set that is popular inside the dental practice, and should not bejust for the management team. Passive employees kill the dynamism of a practice. Employees in a successful practice sustain their ownership by constantly challenging colleagues, not just getting along. They refuse to settle back into a leisurely pace of decision making. And they pursue new sources of value.

3. Ensure ownership down the line.

During the integration phase, there is an inevitable tendency for management and outside advisers to set the targets. We suggest this model be resisted. Practices’ with large front and back office teams that own centrally imposed initiatives, embedded in budgets without buy-in from managers, are most at risk of falling back into their old ways.

4. Execute relentlessly.

As with the incorrect bonus program, it’s all too easy for dental practices’ to allow the pace to let up once the initial improvement targets are achieved. After all, it’s simpler to delegate. But when the practice managers go back to high-level target setting and avoid immersing themselves in the details—perhaps on the dubious pretext that they don’t want to micromanage—the red flags should begin to raise.

5. Address underlying mind-sets.

Inspired employees make all the difference in a practice and in our experience conspicuously outperform those imprisoned by traditional command-and-control culture. Managers should not just challenge; they must instill meaning…recognize extra effort. And they should not assume that employees necessarily understand why the practice has to operate in a different way in the future.

Sleep practices’ that sustain integration continue to bring these five disciplines to their monthly operating meetings, to their annual budget discussions, and to their everyday management routines.

Sleep medicine success, they realize, ultimately is not about the scoreboard and whether the practice can deliver 20 or 20 appliances at the end of the month. It is whether the integration has ingrained a repeatable, replicable process that will drive better and better results long after integration is over.

Thinking about sleep medicine #weshouldtalk

Bonus Can Be a Bonus For Everyone!

It Pays to Pay!

Integrating the right team bonus program in any medical or dental office can be a major catalysts to the success or failure of the practice. As an example, with one of our practice management clients, Endeavor has played an active role in creating steady growth over a six year engagement - that’s production growth from $675,000 to $4 million…in six years! We’ve helped a number of practice start-ups that have gone from zero to $200,000 per month in less than five months. Others from zero to $160,000 per month in seven months! Never would any of these feats have been realized had it not been for team bonus programs.

Have you ever gone to the car wash and had your car cleaned or dried by the owner or manager rather than one of the employees? Perhaps they were busy or shorthanded and management had to pitch in?! Did you notice a higher level of service? Probably. The reason is because the manager/owner has a high level of vested interest in the business, and therefore your level of service was higher than from the non-owner employee.

The same can be said for your practice. The vested interest you have in your practice is much greater than that of your employees. But, what if you could increase your team’s level of vested interest and their feeling of “ownership” in your practice? What if your team became more like business partners than employees?

What if staff worked together as a team to ensure patients’ treatment can be worked into the schedule today instead of waiting until next week? What if time was spent explaining to a patient what might happen if they fail get that broken and decayed tooth fixed with a crown?

What if staff became excited as they showed patients the veneers on their own teeth and talked to about how great his or her new smile would look if they too got veneers? What if your financial coordinator figured out a way for the patients to afford their dental work with a combination of financing, insurance and treatment in stages?

Could this impact the amount of dentistry that patients decided to do in your office? What if you performed 50% more of the dentistry that you recommended? Wouldn’t that mean 50% more revenue on the same number of patients? How would that impact monthly income in your practice? Would this lower your stress level? What would this be worth to you?

A competitive bonus program will incentivize your staff and provide them a sense of ownership in your practice. The right bonus program might also even lower your stress because it brings a willingness of your staff to take on more responsibility. The right bonus program is a win/win for staff, the patient and can bring great benefit to your bottom line. The right bonus program will not cost you money, but will make you money! The right bonus program can change your practice, change your life and the lives of your staff.

On the other hand, the wrong bonus program can actually do harm to your practice and even be a disincentive for staff. Untold number of dentists have tried bonuses in the past that didn’t work for them. Staff rarely, if ever, made bonus – or if they did bonus, the bonus was so small that there was no incentive value. This is typically due to other issues limiting growth in the practice, which needs to be addressed before implementing the bonus program.

On the flip-side, over the years, Endeavor has had to “unravel” practice bonus programs that were developed by well-meaning dentists or “consultants”, but have actually ended up costing the doctor thousands…tens of thousands of dollars - staff was taking home a great bonus while the doctor’s income suffered.

Implementing a bonus in your office can be a bit of a dilemma. Your practice will have growth with a bonus, but the practice needs to be in a growth mode first before implementing a bonus. In other words, if the practice is not turning a profit then the bonus dollars will just come out of the doctor’s salary.

A bonus system is also not the end-all-be-all. Most medical/dental offices have several other issues that need to be cleaned up first before a bonus program is implemented. That is to say, a bonus program will not fix the wrong employee, or weak or non-existent systems, or poor case presentation techniques.

Upon engaging a new client, Endeavor typically begins working on several aspects of the practice…internal systems, organization, hiring the right people, efficiency, case presentation, phone techniques, etc., to set-up the practice revenue so there is now income available for the bonus to draw from. Once at peak level of performance, in combination with the bonus we very frequently see practice revenue increases in the 50-100+% range.

We also develop financial benchmarks that must met for a consecutive 90 days before implementing a bonus program - production at $25,000-$30,000 per doctor and hygiene treatment room per month. The practice should also be producing around $25,000 per employee per month.

A practice with four treatment rooms and four employees should be producing around $100,000 per month. We also want to see employee payroll expenses (bonus included) around 25-30% of collections. Payroll employee expense below 25% is typically an indication of a capacity blockage, and the resulting cost in lost production far exceeds the perceived savings.

There are a number of basics in the bonus program - many nuances and variables that cannot be covered in a blog post, so engaging the right consulting firm to help implement a bonus program so you get it started right and avoid some potential pitfalls. 

There are probably fifty bonus formulas in existence…collections…production…production minus write-offs plus collections and on and on…

Once the proper program is established, the bonus must be calculated and paid monthly. Anything beyond that makes staff wait too long - staff needs instant pudding! It is also important that everything is open and “above board.” Each staff member should know how the bonus was calculated each month and how much of the bonus each staff member received.

Things to consider…if staff gets the bonus too often then won’t they come to expect it?  Of course they will! If doing their job, they should come to expect it every month! If someone expects bonus without working hard, then you have the wrong person working for you!

The end all is that you receive after you give. You give first then you receive. So, when you distribute bonus, this should mean that your practice has received many times over - if bonus is 15% of profit, your practice profit margin is much higher than if bonus was not given. Lower stress, smoother running practice, happier staff, better patient care, growing practice, wealth, etc.

Want to double your revenue in 2017? #weshouldtalk

Four Plus Four Equals...Tired!

Sleep Deprivation May be Hiding in Plain Sight!

Have a toddler? Ask anyone you know who does or has had and they'll tell you that exhaustion doesn't always look how you'd expect. Obviously, sleepy little ones yawn and get cranky when they're tired like the rest of us, but let them get even a little more sleep deprived and they enter a state much feared by parents - overtiredness.

Often diagnosed as the ubiquitous “ADHD” when overtired, little kids will run around with manic energy, bouncing off the walls, and denying vehemently that they're tired. (Usually, to the point of a massive tantrum making it all too apparent they're actually exhausted to the point of near psychosis.) Kids sometimes even struggle to fall asleep when you finally wrestle them into bed because they're so amped up at that stage.

Turns out, many adults are actually similar. Sure, if you're up too late the night before, you'll feel all the classic signs of being under-rested (heavy eyes, yawning, etc.), but if sleep deprivation is cumulative, resulting from weeks or months of sound, restful sleep, your body will try to compensate.

In some cases, you'll begin to show signs that your sleep deprivation has entered a critical phase. If you see them, it's time to seriously consider revamping your sleep schedule.


If you can't keep your hands off the carbs and candy, it's time to have long think about whether you're really getting adequate shut-eye. Apparently, being inadequately rested can cause your body to produce more ghrelin, a hormone that makes you feel hungry and crave fatty and sugary foods in particular, and less leptin, the chemical that signals when you're full. If the brain doesn't get the energy it needs from sleep it will often try to get it from food.


If it's approaching bedtime and you feel like you're flying, it's reasonable to think that your sleep deficit can't be that bad. But, that's exactly the wrong conclusion to draw from your night-time second wind. Your body is keeping you up for that last stretch of the evening so it can get you back into a rhythm. What frequently occurs is that after you’ve been running on empty you promise yourself you'll go to bed early. 'Early' rolls around and you feel fine, so you keep getting things done...but then end up with only 4 hours of sleep (again).


The sun seems so bright and cheerful, the coffee tastes soooooo good and that cat going nuts with the empty cereal box is just hilarious. Is this a sign you're wildly happy with your life? Perhaps, but it could also be a signal that you've become too tired to control your emotions. The same could be said of feeling particularly dejected for no apparent reason. Ever find yourself tearing up over an embarrassing TV commercial? Sleep-deprived brains Are 60 percent more reactive to negative and disturbing images.


Beyond just your emotions, when you're sleep deprived, it's your body too. We don't know exactly why, but sleepy people seem to have slower and less precise motor skills. In fact, miss enough sleep and you could end up effectively as uncoordinated as a drunk person. Going even for one night without sleep results in being about as impaired on early morning hand-eye coordination as someone who has a blood alcohol level of 0.10 percent.


If you haven't had a break out this bad since you were a teenager, it's time to seriously consider whether your sleep schedule might be to blame. Your skin can also register your exhaustion simply by looking older. Poor sleep habits can begin making skin less firm and hydrated - in a word…older. Cortisol spikes in people who are stressed and sleep deprived can break down skin collagen, which stops it from being its usual smooth self.

6. LIBIDO...

Sleep deprivation can take a severe toll on your sex drive, and not just because, at some point, the only thing you want to do in your bed is sleep. For men, sleep deprivation can lower levels of testosterone, which also lowers their interest in being intimate with their partner.


Creativity demands a lot of cognitive resources and when you're sleep deprived you simply don't have that much mental horsepower to spare. You might start resorting to tired cliches and regurgitated presentations to keep up your end of conversations and responsibilities.


If you keep coming down with the sniffles - or can't seem to kick that never-ending cold - you may want to assess your sleep schedule. People who sleep fewer than seven hours each night have almost three times the risk of catching a cold than people who slept for at least eight.

While sleeping, your immune system produces proteins knowns as cytokine, that help protect against infections and inflammation. A few nights of poor sleep could lower your body's defenses against pesky viruses.

Do any of these worrying signs apply to your patients? #weshouldtalk

Is Healthcare Delivery Finally Back-to-the-Future?

The Telemedicine Revolution is Here

Year after year of big promises, telemedicine is finally living up to its potential!!

Being driven by faster internet connections, ubiquitous smartphones and ever-changing insurance standards, more health and dental providers are turning to electronic communications to do their jobs—and it’s upending the delivery of the health care system.

Doctor and dentists are linking up with patients by phone, email and webcam. They’re also consulting with each other electronically—often making split-second decisions on heart attacks and strokes. Meanwhile, patients are using devices to relay their blood pressure, heart rate and other vital signs to doctors so that they can manage chronic conditions at home.

Telemedicine also allows for better care in those rural locations where medical expertise is hard to come by.

At least ten times each and every day, Doctors Without Borders relays questions about tough cases from its physicians in Niger, South Sudan and elsewhere within its network of over 280 experts around the world, and back again via the internet.

In the many rural communities across the country, shifts of doctors and nurses work around the clock in “virtual care centers”… “hospital without beds” providing remote support for intensive-care units, emergency rooms and other programs in smaller hospitals from North Carolina to Oklahoma. Many of them without a 24/7 on-site physician.

Critical-care doctors sit at oversize video monitors, continually collecting data on far-flung ICU patients and watching for signs of imminent trouble. If a patient needs attention, physicians can zoom in via two-way camera—close enough to read the tiny print on an IV bag.

In the past eighteen months, ICUs monitored by specialists have seen a 35% decrease in patients’ average length of stay and 30% fewer deaths than anticipated. That translates to 1,000 people who were expected to die who got to go home instead.

As a measure of how rapidly telemedicine is spreading, consider: More than 15 million Americans received some kind of medical care remotely last year, according to the American Telemedicine Association, a trade group, which expects those numbers to grow by 30% this year.

This is not to say that telemedicine has found its way into all corners of medicine. A recent survey of 500 tech-savvy consumers had found that 39% hadn’t heard of telemedicine, and of those who haven’t used it, 42% said they preferred in-person doctor visits. In a poll of 1,500 family physicians, only 15% had used it in their practices—but 90% said they would provided they were appropriately reimbursed.

What’s more, for all the rapid growth, significant questions and challenges remain. Rules defining and regulating telemedicine differ widely from state to state and are constantly evolving. Physicians groups are issuing different guidelines about what care they consider appropriate to deliver in what forum.

Some critics also question whether the quality of care is keeping up with the rapid expansion of telemedicine. There’s also the question of what services physicians should be paid for: Insurance coverage varies from plan to plan, larger federal plans cover only a narrow range of services.

Telemedicine’s future depends on how—and whether—regulators, providers, payers and patients can address these challenges:

Are patients trading quality for convenience?

The fastest-growing services in telemedicine connect consumers with clinicians they’ve never met for one-time phone, video or email visits—on-demand, 24/7. In the case of a dentist treating obstructive sleep apnea and looking to meet requirements of a “face-to-face” physician visit, telemedicine eliminates the need for the patient to make a trip to the physicians office and, from a cost perspective, the telemedicine consult costs around $45, compared with approximately $100 at a doctor’s office.

Many health plans and employers have rushed to offer the services and promote them as a convenient way for plan members to get medical care without leaving home or work. Nearly three-quarters of large employers will offer virtual doctor visits as a benefit to employees in 2017, up from 48% this year.

Web platforms such as Teladoc, Doctor on Demand and American Well are expected to host some 1.2 million such virtual doctor visits this year, up 20% from last year, according to the American Telemedicine Association.

But, there is always the concern that such services may be sacrificing quality for convenience. Consulting a random doctor patients will never meet, they say, further fragments the health-care system, and even minor issues such as upper respiratory infections can’t be thoroughly evaluated by a doctor who can’t listen to your heart, culture your throat or feel your swollen glands.

In the May 2016 JAMA Dermatology, researchers posing as patients with skin problems sought help from 16 telemedicine sites—with unsettling results. In 62 encounters, fewer than one-third disclosed clinicians’ credential or let patients choose; only 32% discussed potential side effects of prescribed medications. Several sites misdiagnosed serious conditions, largely because they failed to ask basic follow-up questions.

The American Telemedicine Association and other organizations have started accreditation programs to identify top-quality telemedicine sites; the association also tells consumers to be wary of sites that sell products.

The American Medical Association has already began approving new ethical guidelines for telemedicine, calling for participating doctors to recognize the limitations of such services and ensuring that they have sufficient information to make clinical recommendations.

Who pays for the services

While employers and health plans have been eager to cover virtual urgent-care visits, insurers have been far less willing to pay for telemedicine when doctors use phone, email or video to consult with existing patients about continuing issues.

Thus far, 32 states have passed “parity” laws requiring private insurers to reimburse doctors for services delivered remotely if the same service would be covered in person, though not necessarily at the same rate or frequency. Medicare lags further behind. The federal health plan for the elderly covers a small number of telemedicine services—only for beneficiaries in rural areas and only when the services are received in a hospital, doctor’s office or clinic.

Bills to expand Medicare coverage of telemedicine have bipartisan support in Congress. Opponents worry that such expansion would be costly for taxpayers, but proponents say it would save money in the long run—as much as $2 billion over 10 years.

Doctor-to-doctor consultations are also seldom covered by insurers. Health systems such as Mercy, the Mayo Clinic and the Cleveland Clinic that provide oversight and expertise on strokes, intensive-care units and other specialty care to networks of smaller hospitals typically charge those facilities a monthly fee, which generally cannot be charged to patients.

These arrangements enable small hospitals to provide top-flight care to patients on-scene and to suggest that they partner with world-class health-care systems. And it’s less expensive than hiring their own specialists…a win-win…win!!!!

With the 2016 election behind us, the future of ACA is uncertain and the likelihood of HMO becoming more prevalent, hospitals are likely to invest in telemedicine systems to move away from fee-for-service payments and prepare for managed-care-type contracts that give them a set fee to provide care for patients and allow them to keep any savings they achieve.

Is the state-by-state regulatory system outdated?

Historically, regulation of medicine has been left to individual states. But, more and more, the 50 states set of fees, licensing fees and even definitions of “medical practice” makes less sense in the era of telemedicine and is hampering its growth.

Currently, doctors must have a valid license in the state where the patient is located to provide medical care, which means virtual-visit companies can match users only with locally licensed clinicians. It also presents administrative hassles for world-class medical centers that attract patients from across the country.

At the Mayo Clinic, doctors who treat out-of-state patients regularly follow-up with them via phone, email or web chats when they return home, but they can only discuss the conditions they treated in person. If the patient wants to talk about a new problem, the doctor has to be licensed in that state to discuss it. If not, the patient should talk to his primary-care physician about it.

To date, 21 states have joined a compact that will allow a doctor licensed in one member state to quickly obtain a license in another. While this move is welcoming to some, some telemedicine proponents would prefer states to automatically honor one another’s licenses, as they do with drivers’ licenses.

But states aren’t likely to surrender control of medical practice any time in the near future, and most are considering new regulations. So far, in 2016, more than 200 telemedicine-related bills have been introduced in 42 states, many regarding what services Medicaid will cover and whether payers should reimburse for remote patient monitoring as well as store-and-forward technologies (where patients and doctors send records, images and notes at different times) in addition to real-time phone or video interactions.

What counts as practicing medicine?

The exploding volume of health information on the internet is raising new questions about what constitutes the practice of medicine. Some web-based businesses enable consumers to consult doctors overseas, who don’t have U.S. medical licenses, but post fine-print disclaimers that they are providing information and not medical advice.

Are such services “practicing medicine” without a license? The exact definition varies from state to state, and state medical boards generally don’t investigate unless a patient files a formal complaint. Even then, boards have jurisdiction only over individual doctors licensed in their state, not companies, or physicians overseas.

How will this change competition?

Telemedicine is shaking up traditional relationships between providers and payers and fueling the rise of medical “megabrands” whose experts are increasingly competing for patients in each other’s backyards.

Insurers such as Anthem and UnitedHealth Group are offering their own direct-to-consumer virtual doctor-visit services, rather than simply paying for plan members to use those from web-based vendors. Major health systems are making their physicians available for virtual follow-ups and chronic-disease management, as well as urgent-care visits, to new and existing patients.

Endeavor Health is working with our medical doctor clients to create a “Clinic in the Cloud” that would allow rural and incapacitated patients across the country to access physicians without going to an actual office . This will open up a world of relationships across a spectrum of health-care providers that we haven’t seen to date!


If your practice or health organization sees telemedicine in your future #weshouldtalk

Bridging Gap in Medicine Practice and Healthcare Business

Physicians Now Make-up Over 40% of Mid-career Business School Enrollment

Revenue Cycle Management, Incentive Compensation, and Workflow Analysis. These are words that are rarely, if ever heard in medical school but are critical to a physician’s ability to operate their office. Pay for Performance, Profiling, and Payment Methodologies. Other words that physicians are faced with every day but not taught in medical school or residency programs. In our 21st century, you need to be not only a physician but also a businessperson to succeed in today’s healthcare environment. While many physicians play golf on their day off, significant number these days are reviewing accounts receivable. Having an interest in business make it easy to navigate the changes in medicine that are ever-changing, but just as importantly, it is necessary if you hope to operate a successful practice.

Traditional IPAs, PHOs, and Networks have now been replaced by ACOs, Medicare Advantage Plans, EBM (Evidence Based Medicine), and P4P (Pay for performance). There is much more to the practice of medicine than the knowledge learned in medical school and residency. How does a doctor bridge the gap? Every doctor has the capacity to learn how to manage their business and those that do will financially do better than those who do not. What ancillary services can you provide that will enhance your practice revenue? What are my competitors (yes they are in competition with you for market share) doing that I am not. Why do other physicians in my specialty seem to be making more than me? These are the questions that need to be asked on a quarterly basis so that you are not left behind. Although time is a limiting factor, giving up a day off every now and then to make sure your practice is working well is a fair trade. Your office manager, practice management consultants, accountants, attorneys, and others can make recommendations, but in the end the physician has to take ownership for implementation. If this is not the way you want to practice, the alternative is to become an employee of a hospital, large medical group, or other organization and only have to worry about seeing patients. 

In adversity, there is always opportunity. This sentence allowed many entrepreneurial physicians to create successful medical management companies and is going to allow a new generation of entrepreneurs to flourish as health care reform takes hold. As a physician, I have traveled between the business world and the medical world seamlessly. When a physician talks to lay people in business about health care they listen. It is critical for the physician to leverage that in their discussions with managed care organizations, hospitals, etc.

The economics of healthcare has always been that the total expense for any service is equal to the sum of the price for the service multiplied by the quantity of services. In a fee for service world, this is borne out in Florida because as the unit price for a service was reduced the number of services increased. Hence, Florida’s utilization is one of the highest in the country. In a capitated world where the total expense for services is fixed, the quantity of services is reduced leading to a higher price per service but in some instances, underutilization.


It is critical for all physicians to understand that with their signature, they control almost 100% of all health care expenditures while at the same time they only receive 18% of all funds spent. With the advent of ACA, the world as we know it has changed. What is quality care and how do you get there? Is cost effective care the equivalent of quality care? How do I compare to like physicians with similar patients as it relates to utilization of resources and outcomes? For individual physicians or groups to be successful, they will have to prove that they can deliver a better product than their competitor. This is the next phase in the evolution of medicine. The bridge between practicing medicine and running a business is getting shorter. How we take advantage of the opportunity will determine our viability in the future.

What's the health of your medical practice? #weshouldtalk  

It's Not Your Job

The Risks of Bending The Dental Sleep Rule

Every health and dental discipline and every health and dental organization develops protocols to guide staff and providers. Yet there are times when they seem to hinder the ability to offer the best care to patients. What does the doctor/dentist do on these occasions? In many cases, health and dental providers may choose to bend the rules.

A common example may be a scenario wherein the dentist treating obstructive sleep apnea chooses to ignore insurance company polices prohibiting the dentist’s involvement in the diagnostic process(es). A dentist may decide that providing the testing equipment to the patient will assist in the patient’s flow thru the sleep medicine process. Depending on the model, this scenario may also produce some bit of revenue for the dentist.

This case involves a few levels of rule-bending in the “interest of patient care”. And, in many cases, the practice may even become part of a practice’s routine as a result of the provider engaging an outside entity on a contractual situation. But most legal experts agree that bending these rules— even with the best of intentions—is risky business.


Health and dental providers bend the rules for a number of reasons. In some cases, it’s because they’re unfamiliar with the rules, policies or regulations that govern their practice. Or they may believe that their professional judgment overrides any policies or procedures in place.

People don’t go to work intending to break the rules…rule-bending is a learned behavior that often becomes culturally acceptable. These situations occur when health and dental providers act responsibly by putting the patient’s best interest foremost—but at the same time act subversively by stepping outside the guidelines of the scope their practice.

Responsible subversion may help explain why rule bending is tolerated within various health and dental disciplines. As providers try to assimilate into a new service, they learn how to handle certain situations, taking into account how their co-workers and individuals in authority will react. They learn that some things work and some things don’t. 

Once providers have bent the rules and had a favorable outcome and response from patients, perhaps have been paid through insurance, they are likely to be tempted to continue the practice(s). If left unquestioned, the rule-bending action then tacitly becomes acceptable practice in the practice.


Bending the rules is a slippery slope.  Once you start bending a rule, then you start bending it a little harder and a little harder and a little harder.

In fact, bending the rules even once can land you in trouble. Take the case of the dentist who decides to sidestep testing protocols with all patients. Eager to promote their sleep medicine practice, the dentist decides it’s time to perform or participate in testing all patients. During a random audit, the insurance company - or even worse, Medicare - discovers that the dentist has had some role in the diagnostic process and all previously treated patients now undergo audit. The potential result is the payers’ requesting refund of all monies paid to the dentist for sleep medicine treatment(s).

There are additional ramifications for such practices. Regulatory agencies look at certain things to determine scope of practice and can conclude that these practices fall outside of the licensure of the dentist. In fact, in a recent conversation with Awet Kidane, Program Director of the California Dental Board, "The dentist is prohibited from participating in any way with the diagnostic process of a medical treatment. For sleep apnea, the testing device can not even pass through the dentist's office". The dentist even as much as providing the patient with the sleep testing equipment falls outside of the scope of California dental licensure. 

It doesn’t matter if a patient is harmed or not! In many states - California included - performing a task outside your scope of practice is grounds for disciplinary action by the regulatory agency. The result: You can be sanctioned, have limits placed on your ability to practice or have your license taken away. A report of the incident could result in criminal charges.

In addition to the legal and administrative actions that can be taken against the practice, bending the rules can adversely affect your relationship with a patient. A patient who becomes aware that a health or dental professional flouts the rules may lose trust in that provider. That distrust could ultimately cause a patient to become dissatisfied with his or her care, or even derail the patient’s progress—increasing your risk of being sued.


While legal experts agree that rule-bending is inadvisable, they acknowledge that there are gray areas. For example, when a patient’s prescription has run out of refills, a pharmacist who is unable to reach a prescribing practitioner may decide to dispense enough blood pressure medication for the patient to take until the pharmacist can contact the prescriber. While that action could put the pharmacist at risk—he could be accused of practicing medicine without a license—in some cases, he might also have a duty to provide that medication.


Bending the rules is often just a Band-Aid for a bigger problem in the availability of options. Providers resort to bending the rules because they believe they have no other options. But they do. 

If you have your own practice, you may not even be aware that you’re bending rules. It’s a good idea to have an outside organization conduct a periodic risk assessment to identify any risky behaviors you or your colleagues may have inadvertently adopted.

Of course, your ultimate safeguard is to be familiar with and make sure you thoroughly understand both the rules and regulations that govern your practice, and the policies and procedures in place. If you require guidance on your discipline’s code of ethics or standards of practice, you should seek the advice of a qualified consultant or attorney. Similarly, your organization’s risk manager can help you interpret—and adhere to guidelines and policies. The easiest measure of determining if a service/treatment falls within the scope of your licensure is to confirm if you can or can not be directly reimbursed by an insurance company or Medicare. If the answer is no, you likely are providing a service that may place your practice at risk! There are a number of resources which can help you determine how best to avoid liability.

Uncertain about the scope of your practice or ability to perform certain services? #weshouldtalk


Successful Practice Deployment

Common Missteps in Physician EHR Deployment

Despite the fact that Electronic Health Records have existed in some form or another for the last 15 to 20 years, surprisingly, we find that when on-boarding new clients, many are behind the times in terms of how they work; what they do, and, most importantly from a physician's perspective, how they facilitate delivery of healthcare.And, oddly, this is likely a perspective that many physicians agree on.

In a 2015 Physicians Practice Technology Survey, only 53 percent of 1,181 respondents said they had a fully implemented EHR system. And, despite seeing an improvement in documentation (66%), 68% said they did not see a measurable return on their investment in EHR. Respondents said one of their top information technology problems was "a drop in productivity due to our EHR," indicating a significant disconnect between the intent of EHR and its reality.

If you are wondering what EHR trip-ups other physicians are struggling with, consulting pods at Endeavor Health have concluded the following to be the most prevalent when working with new clients:


Inadequate training on EHR systems for both physicians and clinical staff can be a significant source of frustration. Yet there are many other demands for a physician's time and money. It is a paradox that devils many practices: If a practice doesn't go "off line" and dedicate enough time to initial training on the EHR, implementation and subsequent productivity will suffer. But few practices can afford to take a full week or more away from patient care.

Endeavor Health counsels new physician clients to avoid learning a new system while they are seeing patients. We realize EHRs have learning curves and, for some they may be steep. If you do not ascend the curve in a productive learning environment, you will be paying for it with wasted time and frustration.

With our entire network of physician clients, Endeavor Health incorporates technology use in order to have true success with understanding and efficiently using the EHR so as to enable our physicians to commit time each week to relearning [the system]. We recommend practices’ carve out one to three hours each week for a single physician or staff member to learn the functionality of the practice's EHR. That person becomes a liaison or a de facto liaison to the Endeavor consulting pod and can also be a person who can educate and provide ongoing education for the physicians and the office staff.


• Training should be timely, and repeated for both new staff and current users.

• Training should focus on specific tasks that staff/providers will use daily.

• Identify a practice "super-user" who will be a clinic resource/trainer/ IT support person.

Endeavor Health supports a client network of 64 physician practices many of which often struggle with spending too much time on documenting the patient encounter in the EHR. We encourage physicians, PA’s and NP’s to chart on the computer when the patient is in the exam room. All too often, this proves to be a cumbersome task. It can be very difficult for physicians follow this protocol when they are trying to talk and listen to the patient. But, with the recent requirement of medical doctors to move to electronic charting and the impending 2018 conversion for dentists, this will soon not be left up to choice!

Completing the patient note while the patient is present in the exam room is a necessary component of providing a summary of care for the patient to bring home — a meaningful use requirement. So, physicians who are not ace typists, being required to enter the patient note during the encounter can slow down their day and reduce overall productivity.

Another productivity drag? Physicians commonly fail to make use of time-saving EHR features like shortcuts, templates, built-in coding, and voice recognition software to dictate the patient note. And, when visiting other clinics, the doctor often sees them using out-of-the-box templates provided by random vendors, which slows down physician work flows. Engaging the right management firm will better enable your practice to understand your practice's work flows and how they are affected by the EHR. Additionally, the right firm can work with your practice to create customized templates that will speed up documenting the patient encounter.

Many EHRs have the ability, with time and effort - and that's the problem - to make some modification to these templates. But most physicians find those barriers too high, in terms of time and effort. Endeavor Health consulting pods will correctly configure the EHR during implementation so that things like an incorrectly set up dictionary does not create a negative affect for years to come!


• Integrate the EHR into clinical work flows, and revisit work flows after implementation.

• Develop templates/customization that work for the specific practice.

• Ask the vendor for system enhancements to facilitate improved work flows, where possible.


Many practices have vendor-provided tech support onsite for the first week of EHR implementation, and after that they are essentially on their own. Obviously that can be a huge detriment to a practice. Endeavor Health administrators provides tech support with a return visit within 90 days after the initial implementation, for one or two days, to answer questions that have cropped up at the practice.

Communicating with the our clients on a regular basis is crucial to the successful rollout of EHR! We suggest that the appointed EHR "super-user" be our liaison to the practice. This person should not only be communicating back to the our pod(s) what they need and what's working, but they should be communicating back to the office what updates are coming out for the software.

Large health systems typically have their own onsite tech support, which is a definite plus for busy practices. But that doesn't always mean your practice can get the personal attention it deserves. Endeavor consulting pods also act as an EHR optimization team. The goal here is to make that system work better for you. Our consultants have EHR exhaustive experience and approach their work from a "lean-thinking" perspective.


• Build in adequate tech support in the initial vendor contract, with a return visit within 90 days.

• Develop a practice work group (physicians and staff) that will initiate and support EHR implementation/use.

• Task the EHR super-user to act as a vendor liaison.


According to a member survey of the American College of Physicians, most of whom were experienced EHR users, 89% of respondents said they experienced slower data management; 63.9% said the SOAP (subjective, objective, assessment, and plan) note documentation took longer; 33.9% said it took longer to review medical data; and 32.2% said it took longer to read another clinician's note using EHRs.

If your EHR finds you on the low end of the learning curve #weshouldtalk


What You Need To Know

Stark Law and Anti-Kickback in Dentistry

Investigations, audits, and indictments related to the Stark Law and Anti-Kickback Statute violations in the dental sleep community are beginning to become common place in dental circles. Unfortunately, most dentists who are at risk of violating these federal laws may not even be aware these laws exist.

Why is it dentists and dental practices should be concerned about the Stark Law (SL) and the Anti-Kickback Statute (AKS)? Many dentists and dental practices are making deals with physicians to get referrals for Oral Appliance Therapy. The SL and AKS were enacted to ensure that health care professionals do not enter into prohibited referral agreements and to prevent over-utilization of health care services. If a dentist or dental practice is considering entering into a quid pro quo agreement and arrangement with physicians to get referrals, proceed forward cautiously and ensure that any agreements are in full compliance with the federal SL and AKS, as well as any applicable state regulations regarding patient referrals and payment terms between providers.

Any time a dentist and physician enters into an agreement where the dentist expects to receive referrals and the physician receives some type of benefit, the SL and AKS will be triggered. The federal SL and AKS applies only if providers provide services to patients who are beneficiaries of a government program, including but not limited to, the Medicare and Medicaid programs.  Therefore, if you do not accept Medicare, Medicaid, Tricare or other federally funded plans, these statutes may not apply to you. However, most states have their own versions of the SL and AKS and some states, for example California, Colorado and Florida, are more restrictive than the federal statutes. Therefore, make sure you check your state’s statutes before you enter into any agreements for the provision of oral appliance therapy.

During the past few years, several dental organizations have emerged that are signing up dentists and selling the “right” to implement their dentist/physician referral program within certain zip codes. These organizations and dentists are recruiting physicians to participate in patient screening programs where the dentist get referrals for oral appliance therapy. In these organizations, dentists provide physicians with a dental sleep employee to work in the physician’s office to screen all patients for Obstructive Sleep Apnea (“OSA”).  

When a potential OSA patient is identified, the physician then orders a Home Sleep Test (“HST”). The HST equipment is supplied by the dentist without cost to the physician. The physician is then paid by the patient’s medical insurance or Medicare for the HST and OSA diagnosis. After the diagnosis of OSA, the physician then rewards the dentist with a referral for oral appliance therapy. After oral appliance therapy is completed, the patient returns to the physician’s office for a final HST to confirm efficacy. The physician is again paid for an HST by the patient’s health insurance.

Overview of the SL and AKS

The SL (Ethics in Patient Referral Act) prohibits physicians from referring Medicare patients for “designated health services” (“DHS”) to any facility or other entity with which the referring physician (or any of his or her immediate family members) has any financial relationship, unless an exception in the SL or related regulations is satisfied.1 Furthermore, the entity providing the DHS would be prohibited from billing Medicare for the services. The SL also prohibits the entity from presenting, or causing to be presented, claims to Medicare (or billing another individual, entity, or third party payer) for those referred services. The SL establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse.


The original SL (Stark I) applied only to Medicare referrals for clinical laboratory services. Stark II, enacted in August 1993, expanded the prohibition to apply to an additional list of DHS and to referrals to Medicaid as well as Medicare patients. Under Stark I and Stark II, prohibited financial relationships include: ownership or investment interests through equity, debt or other means and include indirect ownership interests through other entities, as well as compensation arrangements including virtually any form of remuneration. Possible sanctions for violation of the SL include: civil monetary penalties, exclusion from the federal health care programs (including Medicare and Medicaid) and forfeiture of all improperly collected amounts.

The following are some DHS prohibited by Stark II :

Physical therapy, occupational therapy, and speech-language pathology services;

The professional and technical components of radiology and certain other imaging services, including MRIs, CT scans and ultrasound services, but excluding nuclear medicine and certain other procedures;

Durable medical equipment and supplies;

Prosthetics, orthotics and prosthetic devices and supplies;

In general, a “referral” is a physician’s request for, ordering of (or certifying or re-certifying the need for), any DHS for Medicare patients, including a consultation request and tests or procedures ordered, performed or supervised by the consulting physician or the physician’s request or establishment of a plan of care involving Medicare DHS. In addition, a physician who directs or controls referrals by others is deemed to be a “referring physician”. A financial relationship includes ownership, investment interest, and compensation arrangements. (42 U.S.C. 1395nn(h)(5).

Durable medical equipment includes oral appliance therapy, and referrals for and the provision of DME between providers, including physicians and dentists, and triggers analysis under the SL to ensure that such referrals would not be a prohibited referral between the parties.

Penalties for Violation of the SL include:

Denial of payment for the DHS provided;

Refund of monies received by physicians and facilities for amounts collected;

Payment of civil penalties of up to $15,000 for each service that a person “knows or should know” was provided in violation of the SL, and three times the amount of improper payment the entity received from the Medicare program;

Exclusion from the Medicare program and/or state healthcare programs including Medicaid; and

Payment of civil penalties for attempting to circumvent the SL of up to $100,000 for each circumvention scheme.

The consequences for non-compliance with the SL are the denial of payment or recoupment of overpayment. Specifically, the SL states, “no payment may be made” for DHS provided in violation of the physician self-referral statute and that “if a person collects any amounts that were billed in violation of the statute, the person shall be liable to the individual for, and shall refund on a timely basis to the individual, any amounts so collected.” Sanctions for violating the statute are often severe and sometimes lead to disproportionately large damage amounts compared to the severity of the violation. Because all claims associated with the prohibited referrals for DHS, even if medically necessary, are not payable, providers who submit such claims are subject to significant overpayment liability. The statute’s overpayment sanction creates a significant potential financial burden on health care providers.

Federal Anti-Kickback Statute

The Federal AKS was enacted to protect patients and federal health care programs from fraud and abuse by prohibiting the use of money, remuneration, either directly or indirectly, to influence health care decisions. The AKS specifically provides that anyone who knowingly and willfully accepts or offers remuneration of any sort and in any manner intended to influence the referral of Medicare and Medicaid services can be held accountable for a felony.

The AKS, 42 U.S.C. § 1320a-7b(b), prohibits any person or entity from making or accepting payment to induce or reward any person for referring, recommending or arranging for the purchase of any item for which payment may be made under a federally funded health care program. The statute not only prohibits outright bribes, but also prohibits offering inducements or remuneration that has as one of its purposes the inducement of a physician to refer patients for services that will be reimbursed by a federal healthcare program. The statute ascribes liability to both sides of an impermissible kickback relationship.

Any person, including a dentist, physician, or other third party or entity, who is involved in making or accepting payment to induce referrals may be indicted. Illegal remuneration includes bribes and rebates, gifts, above or below market rent or lease arrangements, discounts, supplying services or equipment for free or at above- or below-market rates, cash of any kind, whether they are paid directly or indirectly. Almost anything bought by or between medical providers can be characterized as remuneration, if given with the intent to influence medical decision making. If a dentist is providing an employee to a physician to screen the physician’s patients for free or is providing equipment (HST) free or below market rates, the AKS may be triggered.

The federal AKS incurs a criminal violation charge because by definition it requires a specific intent to induce referrals or orders for services. Anti-Kickback violations are punishable by up to five years in prison, with the potential for additional criminal fines up to $25,000, and administrative civil money penalties reaching as much as $50,000 per occurrence. Additionally, the Department of Health and Human Services’ Office of Inspector General may commence administrative proceedings to prohibit anyone convicted of an Anti-Kickback violation from participation in federal and state health care programs or impose civil monetary penalties for fraud, kickbacks, and other prohibited activities.

To assist the federal government in policing the referral process, federal whistle-blower statutes have been promulgated where employees of health care practitioners or other knowledgeable parties can initiate federal or state investigations into referral or kickback violations. The False Claims Act offers whistleblowers an effective way to expose and stop kickbacks in the health care system. Kickbacks, which are hidden financial arrangements between doctors and hospitals or other healthcare providers or companies, are one of the most complicated and troubling aspects of the health care system. Qui tam lawsuits are a type of civil lawsuit whistleblowers bring under the False Claims Act, a law that rewards whistleblowers if their qui tam cases recover funds for the government.

Under the False Claims Act, a private citizen or employee may sue an individual or a business that is defrauding the government and recover funds on the government’s behalf. The qui tam lawsuit is filed “under seal,” meaning that it is kept secret from everyone but the government to give the Justice Department time to investigate the allegations. Even the person or entity being accused of fraud is not told about the qui tam case. The qui tam lawsuit and supporting documents should provide the government with detailed information about the fraud. Under the Affordable Care Act and its False Claims provision a party with general knowledge or suspicion of fraud or violation can act as a whistleblower. As an incentive, whistleblowers receive a percentage of the funds recovered from wrong-doers. Therefore, any disgruntled employee or a dentist practicing next door can take his evidence to an attorney and sue you as a federal whistleblower. Consider the potential risk exposure. Any party with knowledge of a referral scheme could potentially act as a federal whistleblower, including employees and competing providers.


Don’t misunderstand, dental sleep medicine is one of our most successful business functions and we are sympathetic to any dentist struggling to get a dental sleep practice established. We are not trying to rain on your parade. We are aware that it is difficult to establish a referral network!  We are all trying to develop relationships with referring physicians and there is nothing innately wrong with that. However, contracting with companies, owned or operated in any way by physicians, for referrals is too risky for us. DO NOT give a physician anything of value for a referral - playing for interp. of sleep study, renting sleep testing equipment, etc! If you are sued by a whistleblower attorney, it could be financially devastating.  All it takes for you to get into trouble is for you to make a staff member or competitor mad enough for her or him to contact a whistleblower attorney. In the case of an employee, he/she could initiate the lawsuit and still be working for your office since the relater is undisclosed and unidentified. Ultimately, the employee could be paid a portion of any recovery. Sadly, even if you win the case you will lose financially.  You don’t want to be the dentist who has to defend this in court. If you are currently participating in some type of arrangement with an entity that a physician has any financial stake and where you receive referrals, I strongly urge you to consider hiring a good health care attorney and have him review your protocol and any agreements (contracts) that you have with physicians. “If in doubt, Get Out!” #weshouldtalk

Telemedicine is a Thing!

The "Next Gen" ACO

Earlier this year, CMS announced the inaugural class of Next Generation ACO’s – the latest accountable care models - higher levels of financial risk and greater opportunity for reward than have been available within the Pioneer Model and Shared Savings Program. CMS’s goal is to test whether increased financial incentives, coupled with better patient engagement and care management, will improve health outcomes and lower costs for Medicare fee-for-service (FFS) beneficiaries.

One of the most exciting opportunities for these ACOs is the ability to leverage tele-health above and beyond what is currently permissible in fee-for-service Medicare.

Since section 1834(m) of the Social Security Act was codified well over a decade ago, tele-health has only been able to serve Medicare recipients after they’ve gotten in their cars and driven to a clinical site, in a rural area of the nation. Simply translated – no homes or cities count. With the lightning speed of tele-health advancement, this structure is archaic, limiting, and frankly at this point, senseless. Now, with this Next Gen designation, these “Next Gens” will be able to offer care through tele-health technologies regardless of the patient’s location.

So, why should each and every one of these ACOs in this premier class leverage tele-health as a part of their model? For them, the answer is engagement and revenue. For the rest of us – it’s proof. The more patients are engaged in their healthcare, the more successful an ACO will be. Telehealth offers the ability to offer on-demand availability, project care after hours, reduce travel time and expenses, and allows providers to quickly identify and address gaps in care. Combined with the high satisfaction rates tele-health has produced for its end users, Next Generation ACOs have before them a tool that will improve their ability to manage and empower their patients, and improve outcomes through greater touch points.

Then, of course, there’s the dollars. As ACOs make money by keeping the greatest number of patients healthy, tele-health is a key tool in driving revenue. The “anytime, anywhere” nature of tele-health allows ACOs to effectively compete with the rise of retail health clinics and increase covered lives by offering urgent care services 24/7. These technologies can also address increasingly overextended physician supply through load balancing and expand providers’ geographic reach.

The value of tele-health to the freshman class of Next Generation ACOs is undeniable, but these innovators have an ever greater role to play. They can lay the groundwork for the rest of the Medicare ecosystem. For years, tele-health advocates have been championing the cause of expanding tele-health reimbursement within fee-for-service Medicare. And for as many years, the pushback from decision makers has been the unfounded belief that increasing access to tele-health will result in increased costs. Despite concrete proof in the commercial environment that each tele-health encounter saves money, the lack of data from within the Medicare population has resulted in an impasse. These Next Gens have the ability to create the very proof tele-health champions have been waiting for – concrete evidence of the value of tele-health for Medicare enrollees, regardless of who or where they are. #weshouldtalk

Enter the Healthcare Consultant

The Practice/Consultant Relationship

As a management consultants, at Endeavor Health, our job is not just to help healthcare clients to solve business problems, but also to help educate them on the best ways to maximize their return on the investment they are making for our services.

Naturally some physicians and dentists are reluctant to use consultants. They may know that they need help with their practice but are often concerned about costs, and frankly, how to even go about engaging one!

1. Do you need a consultant?

Consultants are best utilized for highly specialized areas, such as insurance contract negotiations, succession planning, strategic business planning, coding audits, practice assessments, practice valuations, mergers, practice start-ups, EHR selection, and those sorts of occasional, single-need projects. If you have needs like these, hiring an experienced expert who knows how to do it right will be worth your investment.

Do not use consultants for things like billing and credentialing, day-to-day management and finance, and human resource management. These are longer-term, daily activities, and as such, you should either hire the in-house experience you need or outsource these functions altogether.

2. What's the difference between outsourcing and using a consultant?

Consultants are usually highly specialized professionals who focus on specific, singular issues and help you to implement solutions. Engagements are usually short term in nature, and designed to produce results in a set period of time, for example, contract negotiations. Pricing is usually based on an hourly rate reflective of the consultant's experience and qualifications.

If you have daily needs that are ongoing, such as patient billing or human resource management, there are many companies to which you can outsource those functions effectively. You will typically sign a service agreement and usually engage the company for a period of at least a year. Pricing for these services are based on long-term contracts and calculated across volume. If would be much more expensive to utilize a consultant to perform these sorts of administrative functions for you.

3. Finding a consultant

Ask your colleagues. There is no better referral than from a colleague who has worked with a consultant and can vouch for the quality of the work undertaken on his behalf. If your office manager is a member of the Medical Group Management Association (MGMA), you can source consultants from that association too. If the consultants listed are too broadly categorized, it can also be helpful to search the internet and see what companies specialize in the specific areas in which you need help.

4. You've found your consultant

Once you have identified a consultant that you wish to contact, make sure that you have a solid outline of your most pressing concerns, and the areas you think you need the most assistance in. A good consultant will want to discuss your needs thoroughly before developing a proposal for you. During that process the issue you think you have may actually be a symptom of deeper problem. Talking through your needs with a consultant first will allow you both to determine the most efficient and effective course of action to take.

5. Signing a contract

Most professionals will clearly indicate the services to be performed on your behalf, identifying clear milestones, developing a set timeline, and listing any information that you will need to provide during the course of the engagement (for example, profit and loss statements, or accounts receivable files, and so on). The contract will also clearly list any costs, when payments are due, and how you will be billed for those services. If detail is missing, ask that the scope of work be clearly detailed in the agreement. You may need to go back to the scope during the course of the engagement to ensure that everything is on track and moving along timely.

6. Working together

At Endeavor Health Management, the best engagements are those in which the client views us as helpful partners and is willing to be as involved as possible. While it may be tempting to move the issue off your desk and onto the consultant's, it is better to collaborate throughout the engagement and make sure that the work being performed on your behalf is consistent with your wishes. If you aren't sure why a project is moving in a certain direction or the basis behind certain decisions, ask questions until you have a complete understanding.

Effectively delivering on the scope of work is always the goal. But from our view, helping physicians and dentists to learn how to better evaluate business decisions going forward and sharing expertise throughout any engagement is always the best utilization of our time. #weshouldtalk