Welcome to setting up and surviving your first year in practice, and thank you for joining us for tonight's webinar. Before we get started, let's review a few items. First, if you need to adjust your audio, please refer to the audio tab and use your device's audio settings. To submit questions throughout the evening, please click the questions tab, type in your question, and click send or enter. Next, if you like webinars, we've got a research one coming up on June 8th. We've opened registration for it yesterday. It's also free and will feature a live Q&A session. Then it'll be recorded and available on demand online. You can also join us for in-live, in-person education. Our annual meeting is right around the corner in July in Washington, D.C., and we've also gotten advanced osteotomies around the knee course in October, and we'd love to see you there. You can register for all of these things now, and I'll put the registration links into the chat box for those of you who may be interested once we get going. For tonight's webinar on setting up and surviving your first year in practice, we have the following learning objectives, and I'd like to give a special thanks to Dr. Michelle Kueh of the AOSSM Enduring Education Committee for her work on this online educational opportunity. Dr. Kueh is an orthopedic, sports medicine, and shoulder surgeon at the Hospital for Special Surgery and an assistant professor at New York Presbyterian Will Cornell, and she'll be moderating our webinar today. With that, I'll turn the mic over. Thank you, Dr. Kueh. Good evening, everybody, and thank you, Alexandra, and thank you, everybody, for being here with us this evening. Tonight, like Alexandra said, we'll be discussing tips on starting orthopedic practice with really a focus on the first year and how to prepare for the next step after your fellowship. The objectives for tonight are three. The first would be to describe the unique aspects of starting practice in a variety of practice settings, be able to explain a little bit about the insurance credentialing and billing process of a new physician, and then develop a list of helpful documents and information to help ease the transition from trainee to practicing physician. So we have a wide variety of panelists today across different practice types, as well as presentations from the perspective of an office manager and then the insurance and billing team. And like Alexandra said, feel free to ask questions in the chat, and we'll have a formal question and answer session at the end. We'll first start with Dr. B. Mercar, who was an assistant attending at the Hospital for Special Surgery in Florida, and he'll focus on overall tips on how to survive and prepare for your first year in practice. And then we'll move on to Dr. Aaron Kasp, who is an assistant professor at the University of Alabama in Birmingham, and he'll focus on particular aspects of an academic practice and how to balance the academic requirements associated with this practice setting. Then we'll move on to Dr. Evan Carstensen, who is in a private practice in Birmingham, Alabama, and he'll be talking about the specific aspects and unique aspects of a private practice setting. And then we'll move on to change gears a little bit, talking with Kerry Sullivan, who has extensive experience with starting a practice, as well as building a successful orthopedic sports medicine practice. And then we'll end with Brian Grabo, who is Assistant Vice President of Central Physician Billing at the Hospital for Special Surgery, and as I've learned as I started my own practice, we do not get much teaching about billing and insurance in our residency and fellowship training, and so I've used him as a resource as I start my practice, and he'll give us a brief overview of billing and insurance credentialing from the perspective of a first year attending. And then we'll end with a formal Q&A session with questions that you guys have put in the chat for us. And so first, we'll turn over the mic over to Dr. Beamer-Karr. Thank you, Michelle. I will start the slideshow. So yeah, thank you again for having me. It's definitely an honor to be here. We'll hop into the first topic, tips for surviving and hopefully thriving during your first year of practice, which basically boils down to what I've learned and what I wish I knew. So I do not have any disclosures. I joke that I'm currently in the market for them, and I also joke that the first lesson is feel free to pursue disclosures a little more tactfully and sooner than what I have. So I like to show this for, you know, these kind of lectures where it kind of summarizes our journey through our medical training. You know, we get into med school, we're very happy, then we realize we're studying all the time, but we graduate, so we become happy again. We go off to residency. We feel so happy because we feel like we're a real doctor. We're ready to, you know, conquer the world and do great things. And then we find that it's really exhausting and tiring and not as glamorous as we thought, but we graduate, so we're happy again. We go off to fellowship. Again, we're happy. We're back to being a happy doctor. We find out that fellowship really is awesome. It's probably the best year of training and maybe the best year of your whole medical career. And, you know, you graduate, you're happy. You get your first two years of practice. You're finally ready. You feel strong. You're ready to, you know, finally be on your own. And then it hits you really quickly that this is, you know, the big leagues and there's a lot you don't know. And pretty soon you find yourself like this meme where you're just sitting around a bunch of dumpster fires trying to convince yourself that everything is fine and you're wondering how do I survive and get through all this. So, you know, really, if you talk to a lot of attendings, the first early practice years are really the most stressful, potentially least enjoyable years. However, while this is generally known, little is done to really prepare us in our training for this challenging time. So, you know, what advice did I give when I was about ready to start? I was told to make sure that I irrigate my wounds. I was told that the first five years of practice are the worst five years of your life. So good luck. You'll be fine. Don't worry. And just don't kill anyone. So needless to say, this advice did not prepare me for what awaited. Really the hardest part is that we're the least prepared in our early years with the least amount of experience, with the least amount of reliable help as we build a practice. Yet patients still require and deserve that same level of expertise and service that are attending through, you know, training gave them. So it really boils down to trying to bridge that gap. And I think webinars like this are really helpful for that. So I just want to real briefly kind of give the top 10 lessons that I've learned. I'm currently in my fourth year of practice and I'm still learning a lot. And these are some of the things that I've learned. So hopefully they can be of service to you as well. The first one, number 10, take some time off before you start at least two weeks, ideally three to four, if not more. You know, I had a mentality of, oh, I want to start right away. I want to be, you know, a good worker and a good employee. And I basically started about two and a half weeks right after fellowship. And I'm glad I took those two and a half weeks. I wish I would have taken more because once you start, once you get on the hamster wheel, it's really hard to get off. So I definitely recommend just treating yourself at the end of training to some time off and enjoy that before you start the journey. Number nine, set goals and stick to them. So as a fellow and early year practitioner, you really should ask yourself, what do I want to become? What do I want to do? And then really kind of stick to those goals. So for me, I wanted to, again, you know, what do you want to become? What are your goals? I really wanted to be a high level baseball surgeon. That was kind of my ultimate goal that I'm working towards. A lot of times I was told throughout residency and even sometimes fellowship, well, that's really hard to do. There aren't really enough Tommy John surgeries to go around. Have you considered doing hip scopes? It's a lot easier to get your foot in the door. And when I was at a residency leadership forum, I was told that, you know, if you know what you want to do, you should just go for it. It may take longer, but it's worth it. So I would just say, you know, set your goals and then go for it. I like to tell people to groom your practice according to what those goals are. So some practical advice for this, it's kind of like this meme up here, this little cartoon, you'll find that you're dug into a position, but then you realize it's not really the position you wanted. So you have to be really mindful from the beginning of what kind of practice you want and how you're going to get there. It will not become what you want on its own. So you have to make it where you want it to be. I tell people and what I do myself is to create one, three, five and 10 year goals for your practice, and then really come up with a tangible plan for how you're going to reach those goals. They can change as you go along, but at least if you have some goals, it really does help you out. And you really have to build and groom your practice. Don't just build it for the sake of building, keep those goals in mind and groom it along the way. I tell people, you know, our practices, we show up, it's kind of like this dog that's really, you know, has crazy hair and then it becomes nice and well groomed. And I also say we have to be careful because a lot of times what you think you're going to get, you ask the groomer to shave a heart on your dog's butt. You think you're getting this, but then you really get this. So you got to be careful with your expectations and what you go for. So some really basic advice that's been really helpful to me is to focus on building initially, but don't forget to groom. I recommend that you group your patients and surgeries into three categories. The first one being the ones you love. The second one being the ones you like, but you wouldn't mind dropping at some point. And the third ones being those that you hate and don't want to be part of your practice. What I recommend is that you aggressively pursue and develop those referral patterns for category one. Initially pursue category two, but groom them along the way, and then minimize category three as much as you reasonably can. I won't belabor all of this. We can, you know, the slides will be available to you afterwards, but basically you just want to ask yourself who are the gatekeepers for your first couple of categories. And then that's your target for networking. PCPs can be a good source. The PTs locally can be a good source. Athletic trainers can be good. Typically I've found that you need to send a few patients to therapists before they send some to you. So make sure you really become an active member in your community in that way. Other orthosurgeons that have complimentary practices can be very helpful. And then sports performance gyms and even chiropractors can be a good source for referrals. Your word of mouth is really your best way to build your practice. So you don't want to forget the A's that Andrews always talks about, availability, affability, and ability. And you really just have to make yourself available. So calling the ATCs, the PTs, the coaches, making sure you update them with your plans and then never really turning away a patient. Every patient is an opportunity to build that word of mouth and then communicate back with the referring provider. Lastly, you should always, you know, say yes early to clinical opportunities, but you don't have to always say yes. Your time is your best asset. Make sure you build your practice accordingly. So I like this picture because these blocks can all be used to build different shapes. You can take those building blocks and build whatever practice you want, but you got to make sure you're building the right thing. So moving along a little more quickly now, building a specialized practice takes a long time. Don't be discouraged when it takes you a long time. You know, I'm in my fourth year and I'm still a long ways off from getting a specialized sports practice. I'm closer than I was when I started, but I still have a long ways to go. My residency chairman would always say it takes decades to build that kind of practice. And sadly, I think he's closer to being right than my unrealistic expectations. It's really hard to build that specialized practice and your practice won't look like your mentors' practice initially. Don't assume that your surgical team kind of knows how you want to do things. You really have to build that as well. And then it is a lot harder operating without another attending. So just be ready for just those struggles and challenges. You will not have a perfect job. That's another lesson that I've learned. There's really great jobs out there, but no job is perfect. When you're assessing your job, you should really ask yourself, you know, there'll be negatives about it and there'll be positives, hopefully multiple positives. And you have to really realize there's no free lunches. You win some and you lose some. And it really boils down to knowing that you'll have to compromise and asking yourself, do the positives outweigh the negatives? And hopefully the answer will be yes. You really have to also ask yourself what's the most important thing and at least make sure you're getting that out of your job. I'd also recommend be mindful of ABOS oral boards from the start. You really want to set yourself up for success the moment you start your practice so you're not having to change things when board collection period comes around. You want to maintain good indications from day one of practice. You want to pretend like you're in board collections from the very beginning. That way it's no different when you're in board collections. Be meticulous, document well, stick with what worked during training. Don't try new techniques. Be ready to defend all clinical decisions with supportive evidence. Be very mindful of not doing industry-driven techniques with little to no quality research to justify those decisions. I think that's where a lot of people find themselves in trouble defending their decisions without research that can justify it. Keep a folder with all your consent forms, including your HIPAA consent form. It makes it a lot easier on the back end. And then really practice, engage your mentors. They will help you. I do want to just show this diagram here, this chart. If you notice, the failure rate last year was much higher, 17% than years past. And while we don't know exactly why that is, I do think a lot of it is attributed to, you know, performing newer techniques that don't have research, things that are harder to justify, and not being prepared and kind of taking, you know, taking it lightly. So the odds are still very much in your favor, but don't sell the preparation short. Be aware of the myths when you start your practice. There's a lot of them. One or two brief ones that I like to talk about is taking call is a great way to build your practice. That is true. And while you certainly have to build call or take call, it may not be an efficient way to build a true sports practice if that's your goal. I would say take call early and often, but don't necessarily rely on that to build a sports practice. It might, depending on your, you know, call situation, but it may not. Patients will want to see you because of your group or hospital's reputation is also a myth. Patients will want to see you because of your reputation, and that takes time to build. A patient asked who should fix my rotator cuff, not where should I get it fixed. And so you really want to, you know, just take time to build that reputation. The last couple of lessons here, don't underestimate the stress of being in attending. There is a lot of stress that comes with it. No one is immune to that stress. Make sure you stick to good indications. Don't let the fact that you're not busy allow you to bend those. A chance to cut is a chance to cure, but there's nothing surgery can't make worse, and you're going to live both sides of that paradox your first couple of years and throughout your whole career. So be ready for that stress. Never force or convince a patient to have you perform their surgery. It will take you longer to do surgery, so schedule your day accordingly. Takes a lot longer to operate when the attending is not there to bail you out. You will struggle, but don't let that struggle prevent you from achieving perfection. As one of my mentors said, you don't want to have a surgery with signs of desperation. Take your time, trust your training, and you'll do great. And be careful about relying on others until you know you can trust them. So you really want to make sure you're setting yourself up for success. Lastly, for the last two, lean on your mentors. I won't go through all of these lessons, but I've had some really good advice from my mentors. It's hard to reassure a patient if you're not sure yourself, so make sure you're really studying and educating yourself. Prioritize your family. Research can be a lot of fun. You never rotate off your own service, so keep that in mind. I like to call my patients the day after surgery. Patients love it, and it's a great way to care for them. If you're doing a tough case for the first time, do it with a colleague. That's really helped me well throughout my first couple years. Incentivize your office staff to perform well. PT never killed anyone. It's always a good place to start if you're in doubt. It takes time to build that good practice, but it takes a long time with word of mouth, and that's the best way to do it. If a patient's having a complication, see him or her twice as often. And as Dr. Russ Warren would say, if I only did surgeries I felt completely comfortable with my first year, I don't think I would have done many surgeries. Lastly, I like to show this. Basically, make sure you have mentors who will share in your highs and lows of your first year. You need to have some good teammates and know that you're not defined by the scoreboard. You're going to have some big wins. You're going to have some big losses. Don't let that affect you one way or the other. Really lean on your mentors and let them be your mentors throughout the whole process. Lastly, direction is more important than speed. I think this is really the main lesson that I've learned. It's going to take a long time to get where you want to go, but you have to make sure that you're going in the right direction. I would just encourage you to set your direction, make sure you stay on it, and don't be discouraged if you're struggling along the way as long as you're heading the right direction. In closing, you're on the verge of a great time in your career. Don't be afraid to lean on your mentors. Enjoy the journey. be ready to learn and I always like to end with this quote from my dad before he passed away he basically said no matter how much medicine changes at the end of the day it boils down to me and the patient in the room I love serving my patients and nothing can take that away from me if you have this perspective you won't have to work a day in your life and my father was an orthopedic surgeon and that was his perspective and he had a very rewarding career because of that and hopefully you can have the same so thank you very much I encourage you to keep chasing your dreams because one day you just might catch them feel free to email me if you have any questions and thank you again for this opportunity thank you so much Dr. Carr and next move on to Dr. Kask who will talk to us about the specifics of an academic practice all right thank you Michelle and I'd like to thank AOSSM for setting this up my talk on surviving an academic practice you know will echo some of the things that Dr. Carr said with some of the peculiar peculiarities of and specific problems that you can face in the first year of an academic practice just an introduction you know I did my my fellowship a couple years ago in Colorado and I'm currently a hip knee shoulder sports medicine surgeon at UAB and I will tell you that the patient population in Birmingham Alabama is quite different from that in fellowship I do a lot of team coverage which is something that can often come with academic practice which we'll talk a little bit about you know the if you think surviving academic practice is hard try surviving an early practice with you know two young kids especially little banshees that you know destroy your house all the time here are my disclosures they're not relevant to current talk so I'm going to talk about today one of them is getting the job and what does academic practice actually look like what does help in the OR look like then your actual clinical practice a quick overview on team coverage and then the actual research and academic involvement and then I know this is sort of focused more on the first year but you have to set yourself up for success for professorship and the long-term academic call so whenever you're first getting into academia you mainly you need to get the job based on your and the university's needs now university openings are usually cyclical and they're often regionally limited when I was coming out there were probably four main academic jobs and they were all regionally very different and so with all the people that you know we were we all knew each other at that point that we're applying for those jobs sort of needed to know what they wanted and where they wanted to be and you really need to be honest with yourself about your academic aspirations do you do you actually want to be in academics we all trained in an academic medical center so that's what we're comfortable with but is that something that you actually want to continue doing you need to figure out what the university actually needs universities often hire based on need and niche me personally there was a hip arthroscopist that left probably a year before I applied for the job and so I got hired specifically to do hip I you know I do a full spectrum of sports medicine surgery but specifically I had to fill the hip but you got to make sure you know what you're getting into because there are often behind the scenes talks about what you'll be expected to do maybe the current staff will say oh yeah we'll hire him to do hip but we really need somebody to fill this this this need that nobody else really wants to take care of so he can be that fill that need and you might not know that but there's you better figure that out quick because what their expectations and the department's expectations of you can really shape your practice early on when you show up you know you might have a big backlog of cases from from the department already you've got your partners who really don't want to do this surgery and you know they might be telling patients oh you know you know you need this surgery but we have a new blank surgeon starting soon so then you can then you can come in and really start you think man I'm really busy this is awesome it's really just a backlog of cases from what you're attending from what your partners have already had going on for you complex things come early this is very true at an academic center where people are putting off stuff and you're a tertiary referral center so as soon as they see some openings you know they might just land on your schedule and because you're starting your schedule is the most open so acute things are going to show up on your schedule first you know I did you know sports medicine training did all these complex sports medicine surgeries in my very first clinic you know this this lady is five days out from a fall and she hobbles into my clinic and this is what she's got she got a trimeo ankle fracture I try and call around and say like hey to the foot and my foot and ankle partners like hey guys like can you guys take care of this and they kind of responded like we're all booked up this week it looks like you have open no more time on Thursday so you know you have to be a generalist first that's true certainly in private practice but it also applies to academic practice as well make sure you take time with your patients when you first show up because you are going to have time to take and then you really need to figure out what your flow is going to be like especially in clinic and and in clinic if you are short with people and people don't know what you know what your preferences are you're gonna get a bad reputation no one knows you or your preferences are and rumors start early so people you know are you know are excited and kind of eager to see a new surgeon starting especially at a university but if you're not the nicest to the staff or anyone around they're gonna they're gonna start talking about it and it's it's just like residency once you get a reputation it's hard to shake it what is helping the or look like that can vary dramatically based on what university you're at and how purely academic you are will you be part of the residency formally will you have a resident assigned to you or are you going to be more sort of a satellite community practitioner within the residency what does an extra set of hands look like do you definitely have a resident are you having a first assist do you have a pa all those things really matter and they can and you would have to significantly adjust your sort of surgical technique and approach based on that operating by yourself is likely very different from your training you know if you have a big case in in training you've got these uh in residency or fellowship you've got these uh you know mature practices with residents and fellows around and you know a big case big case but if it's just you early on no one really cares if you're doing a big case so they're not going to scrub in to watch your your technique you're brand new so you've got to adjust what how you do things based on how much help you have and do you have or time right away during covid this changed dramatically when i first started uh here at uab everything had switched from block time to first come first serve um so i had set days that i could post on but you know i wasn't very busy so i was posting things you know a couple days to a week out and so i might start at 2 p.m uh and that's just how things were when because they were trying to fill in cases where they could during coven um you know you things you have to realize uh when you're planning your or day in an academic center you're part of a system the system is probably not going to bend to you you're going into a system that has been established that has staffing that's established and you're unlikely to have a whole lot of say in the staffing you're probably not going to have a consistent scrub or circulator or maybe help in the or or really anything so you have to be prepared for that uh you have to adjust to the way things run you might come in with all these ideas of how things are going to run but if you're going into a big academic center things run at the pace and at the at the way in which they want to so you can say like you know well maybe i'll just buy into the system and kind of you have to kind of pick your battles you can't fight everything what about your actual clinical practice you know um you will not walk into your mentor's practice that's just uh what unless someone's retiring and handing you a practice you're just not going to it's going to take a while so your open clinic slots means you're going to have a lot of acute and non-operative problems and people come in with just pain and that's uh because it's easy for them to get on your schedule that's who they're going to see good pathology and patients come with time you're a regional referral center you're a tertiary care center so not only are you going to have bad pathology early on you might have unhealthy obese patients on home oxygen that can't have surgery at the local community hospital so those are the people that show up in your clinic you know you may uh show up you know all of a sudden you became the shoulder expert in town and this uh disaster proximal humerus fracture gets shipped in from the hinterlands uh told to follow up with a local shoulder surgeon at the university you know and this might come into your practice within the in your clinic in the first couple months of practice like it did mine and all of a sudden all you want to do is scream i need an adult well you need to realize that again you're a tertiary referral center you are the regional expert you don't really have anyone to punt to and so you are going to have to take care of things and that's just uh the way it is complex problems are going to find you very quickly but the benefit to academics is there's usually lots of help and expertise around so you know you might be able to talk to your one of your more uh senior partners and get their take on it and then you might be able to man up and say okay maybe i just need to do a proximal humoral replacement on this lady with a tumor prosthesis that's not the i can tell you i did zero of these during fellowship but that's just sort of i know the basics of it and i know how to do a reverse shoulder arthroplasty and so that's just sort of what you got to do uh some things that i will just have to let sort of wash over you when you're in academic practice you are going to lose sleep you can't really hide from these problems and you likely have residents watching your examples so you can't really weasel out of things because you've got to set a good example for the trainees and they know when you're trying to weasel out of things so you are kind of under a lot of scrutiny from day one even if it's not from the department but it might be from the trainees that are looking up to you to set an example moving on to team coverage that often is something that is entailed in academic practice um you know this is one of our athletes who just signed with the packers a great guy but and i love spending time with him but you got to figure out what you're expected to do are you getting uh you know the the high demand team or are you getting um more likely something smaller like a high school team it's time consuming if you travel with a division one sport or a university-based sport it takes a lot of time you might have to shut down clinic or owe our days to travel um coming in uh you are probably not not going to get the uh the professional team you might get the least desirable highest demand team first and that's just how it is because there's other people that have worked their way up have the more desirable coverage and do you get paid for it you know it's time consuming there are some places that in hospital systems that will pay uh for coverage or at least incentivize you and some places say you know this is service to the department service to the university and that's just how it goes uh what about actual academics is there a research expectation uh you that those are things that you need to know and you have to get a feel for the flow of resources um you know this every university or department does things a little bit differently and have different resources at their disposable and you need to realize this isn't residency just because someone thinks that something might be a good project does not mean you have to jump on it and say yes to everything you you know you can choose what you are doing from a research perspective and i would highly recommend that you not over commit early on and do you get paid for it that's another thing you know some universities pay um for per uh academic publications some you sort of give a bonus structure based on um sort of your overall academic achievement or academic contribution at the end of the year whether that be society lectures and publications and things like that um when you start in an academic practice you are fresh meat you know the there are tons of academic and university committees uh there is a soft tissue committee that is here that uh you know as soon as i started tried to get me to join what does that mean they just decide what needs to get sent to pathology and what doesn't whenever you're like cutting things out like for example all femoral heads here for whatever reason uh during a hip fracture have to get sent to pathology there's a whole committee that meets reasonably often to do that to decide that there are innumerable committees and you need to figure out your practice first before you start getting involved in and over committed to all these things because if you get over committed uh your practice is going to suffer your everything else is going to suffer and it's just not always fun to sit in a weekly or monthly meeting that doesn't really do anything uh residents and teaching those that has probably been my biggest uh difficulty uh it's you i walked in thinking oh i'm going to be this phenomenal uh teacher this phenomenal mentor i'm going to be able to let the residents do whatever they want because all my uh attendings that i love the most let us sort of run a little bit free it's really hard to give up the reins early because you know how you want to do things and you're trying to figure out how you're doing most of the things your way and let's be honest you're not as confident as you should be and you're probably not able to rescue every single thing that a resident can do and it never surprised it never ceases to surprise me what a resident can mess up during a surgery except that you're going to be hands-on for the first few years you're just not going to be that guy that lets the resident run run wild because it's just stressful and again you don't know what you can fix and what you can't fix from what they do and again residents don't know what they don't know so you know end of pgy2 maybe beginning of pgy3 you're sort of at that peak of mount stupid where they're you know incredibly confident but they actually uh know very little uh much less than they think they do so you know it's it's it's it's always humbling to uh you know for me personally once i give a little bit of slack and something goes wrong uh that's something that you kind of have to get get used to and realize that teaching with uh other learners when you're still trying to learn how you how you operate yourself is difficult and then the academic professorship and long-term girls goals there's always milestones for academic rank learn the formula early and set goals uh there's usually somebody in the department that's on the promotion and tenure committee uh that knows what you know check boxes you have to hit and you need to sit down and make timelines i'm going to get x number of papers done i'm going to do these teaching engagements uh or these society involvements uh you know within the first year or two and that sort of allows you to get on the path because if they if you don't set a path you're going to just kind of get lost in your practice and not do any of that other stuff so in summary academics can be a grind you've got the clinical practice you've got research and teaching and you're expected to stay up to date on the most uh you know modern uh technological and um surgical advances at the time and go to meetings go to courses all while running a practice and that can be very difficult to balance many academic surgeons move jobs you know once a there's often a chain reaction or domino effect once one academic surgeon moves they all start to shift around and if there's a better opportunity somewhere else for better coverage or a more desirable regional location all those things can can happen so you have to be uh sort of you know open to the idea of moving if you want to climb up the academic ladder and you need to set goals and boundaries early that is something that i cannot uh you know there's endless opportunities just like in residency there's endless sort of opportunities uh for learning and there's endless opportunities to get involved from an academic standpoint but you need to basically prioritize what's important to you and then make sure that those things uh stay uh sort of in an appropriate priority order for you that's all i have thank you feel free to email me uh and get in touch and it's been great and thank you again dr q for setting this up awesome thanks dr casp so now we'll have a complimentary but um kind of a partner talk from dr carstensen on how to start a private practice he's been there for several years now so he'll give us his wisdom on the differences between private practice and kind of what his experiences were as he started Seem to have lost all We can hear you we can see your slides if that helps and we can see you All right I'm Evan Carsonson. Thanks. Thank you for setting this up in a OSSM as you can tell by my slides and background I'm in private practice. I have no neat template to go based off of These are my disclosures unrelated to this talk So William Osler said the practice Of medicine is an art not a trade a calling not a business a calling in which your heart will be exercised equally with your head I think that goes Certainly very true. I think we have to also understand that the eyes cannot see what the mind does not know So from a private practice standpoint, it's very important that you understand the business of medicine You will immediately become a primary decision maker when it comes to your practice from day one whether that's in the clinic Or the group of the whole from a decision-making standpoint It's imperative to success It helps you avoid medical legal issues and it's very important You understand how your money is being spent before you even get paid a lot of this with private practice is overhead You want to understand what percentage of your overhead? Is actually coming out of your overall revenue and then you want to understand the overhead and breakdown You will notice that with the overhead whatever percent it may be there are areas that are efficiencies and inefficiencies or stuff You might be able to change To save money and now there's gonna be a lot of stuff that you're not going to be able to learn prior to starting So there is ample on-the-job training and I think the most important thing is that we learn from our mistakes You'll make plenty of them, especially when it comes to billing and coding which we'll talk a little bit about later on You want to understand your practice environment you understand the competition? And not so much that it's not collegial, but you want to know what other practices are around what types of pathology Do they take care of what do your partners take care of? You understand transparency in your group is your group as a whole are the books when it comes to all the finances? Are they closed or they wide open to you? Do you get to see in my practice for instance? We get a profit and loss statement every month where you see everybody's revenue and you see where all the money has gone So it's very easy to kind of follow along and it builds trust in the practice Understanding the practice dynamics the hierarchy with practice partners. Do you have partners who take all certain pathology? They only see certain insurance Providers same thing with how our patients scheduled or all the new patients with certain pathology going to certain providers Or they evenly distributed or they also go into a patient or providers who have openings on their schedule How is the overhead split is it a fixed percentage is a percentage based on collections is it some combination of these two things? These are important things to understand when you're getting into starting to deal with the finances when it comes to medicine You've spent a lot of time learning the medicine over your years in medical school residency and possible fellowship Now you also have to understand some of the business aspects because there's a lot more hands-on that's required in the private practice setting Buying into practice. This is a huge part of it is are you on a partnership track from the get-go? This can this can be widely variable. Some folks are on a Nominal fee to buy in and some at the end of the day you realize I'm just paying off the senior partners who don't do Many cases anymore and they use it kind of as passive income and you want to understand What do you get as a partner? Are there passive income opportunities with DME physical therapy or their imaging centers? That you can be part of when it comes to that Also, what void can you fill is there something you can bring to your practice and to your colleagues that you can help? Start taking care of pathology that I may have previously sent out This can also help increase your referrals and also build collegiality with your with your partners So they know that they can trust you to send these send these patients to you instead of having to refer them elsewhere You want to understand where your patients come from? These six things on the left side. You'll notice that there is going to be an ever-evolving percentage that Generates patients that are going to be flowing through your door You want this picture to be all your patients that are sitting in your waiting room? Happy it's been can be to see you and also you have to keep in mind We now live in a society where reviews are a very important thing For better or for worse and you'll find that a lot of patients will go and look up Who you are where you came from and they'll talk to you about this I think as Beamer had already mentioned to the A's of dr. Andrews before but again, I would say affability availability attentiveness Accessibility and approachability adding on to that adage is very very important when it comes to generating patient flow through your clinic You want to understand how you get paid right a lot of the private practice stuff is an eat-what-you-kill model Especially after you your first few years where you might have been on guaranteed salary. Are you paid via collections most? Most of the private practice positions are that way there are a few that are kind of private emic combinations Where is some RV you base? But it's very important if you don't know how you get paid and it's very hard to generate your business as you go forward Active and passive income like I'd already touched on active is obviously what you're billing collecting But also the passive income opportunity You'll have quite a few of these and you need to really evaluate them and understand what you're buying into Whether that's ambulatory surgery centers MRI centers Physical therapy groups DME products or your own imaging at your office And insurance participation you'll oftentimes you'll have a lot of opportunity to decide What it is you accept? I think as you start out, you know for me it was very important to accept every insurance That I could accept self-pay see workers comp and again as Beamer mentioned previously You can kind of groom this practice as you go But getting the folks in the door first is very important because that's how you generate patient flow and how you get word-of-mouth Referrals coming in the door as well So understand billing and coding. I think this is a huge topic and again We'll have some more expertise on this and I'm not going to go into it too much, but it is vitally important You'll you'll find that we don't do a lot of this coding aspect And it's very very widely Which is widely varied when it comes to the coding aspects You see in this one v91.0 burn due to water skis on fire a subsequent encounter. That's pretty specific, right? But then when it comes to something like a bank art lesion, you'll use this s43 versus superior glenoid labrum lesion of the right shoulder So the ICD 10 coding stuff is very important to learn and there are lots of opportunities. There's YouTube videos you can learn of there are certain courses you can take which are helpful and then obviously your mentors can help you out if You're not sure how to code something or what CPD code to use to build something. You can always reach out to your mentors You want to understand your strengths and weaknesses and I think this is something that can be difficult to do if you're not great at Reflecting and being very honest with yourself, you know for me. It's something when you think what do you do? Well, well in the arthroscopy I see a lot of the sports stuff is a lot better But I think when you start looking at the stuff you don't do well, or you don't want to do Or what do you really struggle with? You know for me? It'd be something like this. This is something that I hope to never see again But it is very important to be honest with yourself understand what it is You do well understand what it is. You don't do well the stuff that you don't do well And if you're not comfortable with it, but it's something you feel like you need to take care of have a colleague help you Reach out to your mentors on how to how to approach these difficult cases because they will be there early and often as Aaron had Mentioned as well Or hiring a nurse practitioner I Wouldn't feasibility and budget for hiring assistants, right your nurse practitioner physician assistant athletic trainer All these folks can make your life easier personally for me I'm only paying about 12% out-of-pocket for my PA due to collections and that's just the way we kind of structured his Involvement and what we do and again, he helps pretty much pay for himself, but he makes my life a million times easier Determine that work-life balance and what you can do to attain this right hiring that mid-level prior that we talked about hiring a scribe in Clinic to limit some of the paperwork that you can spend more time with your family and get home sooner Schedule modification you can decide what you see and when you see it You can decide how many how many folks are you going to see in clinic? Are you going to have 50 open slots? You're going to have 20 open slots again This is something that's going to be groomed over the time It's something that you can hopefully kind of cone down and trim to exactly what you want over time But again, this is constantly going to be changing. You want to surround yourself with those who can help you be successful This goes to the office staff as well as you know, your clinic coordinator somebody who helps you out one-on-one You want somebody who understands what your goal is and help you kind of attain that goal? And then lastly market yourself in person, right? I think we ingratiate ourselves frequently to the other physicians That are around us to try and get these referrals in the door But understanding and meeting the referral coordinators talking to the office staff and that goes back to the five days that were previously mentioned Again, I know this is kind of a quick overview, but please feel free to email me if there are any questions I'm happy to respond the email if there's anything you don't feel comfortable asking in a bigger forum Thanks, dr. Carson said so like everybody's mentioned in the first three talks you can't do this alone You need a lot of help and one of those people who helps you depending on how your practice is set up you either have a clinic manager or practice manager or somebody who directly helps you set up your practice and Helps you answer patient phone calls and any of other my chart messages or things that patients have issues with and that person Talking to us today is Carrie Sullivan and she is an office manager at the hospital for special surgery And she's helped set up a sports medicine practice So she will talk to us about her role and really how to set up your practice from her point of view Hi, Michelle, thank you so much for having me here. It's truly an honor to be able to be a part of this I work for dr. Sam Taylor here at HSS. We are halfway through our ninth year in practice I'm going to talk about the administrative aspects of setting up your practice The first thing you want to do is to establish your schedule hours of operation What your staffing is going to be you want to know what's going to be happening day-to-day your patient care hours You're going to discuss this with your office manager as far in advance as possible Dates that you are not available to be in the office or OR you want to avoid last-minute changes to the schedule Which are sometimes unavoidable due to emerging conflicts Avoiding these last-minute changes helps to reduce the number of angry patients who have to be scheduled We spent a lot of time in our first year Rescheduling patients because of not having block time and you know having to you know, combine schedules So it does definitely help limit the amount of angry patients that you have It reduces office stresses as in trying to find time on your busy schedule to reschedule appointments They do not have to be extended wait time between the cancellation and the reschedule It also helps to reduce the amount of dings that you have on your OR block time Patient hours Understand in the beginning that while you have a set office hours There needs to be flexibility with coming in early staying late to accommodate patients This flexibility needs to be across the board and extend to all your staff in the office This is particularly important for your office manager as they need to understand that they are building a practice with you And this means the ask is often more than just a nine-to-five job, especially in the first year so it's important in this regard to set proper expectations with the person that you hire as Your practice mature matures the routines and hopefully the hours will improve everyone's quality of life at some point One thing that was very important when we started our practice was speaking to established practices Established practices can give you ideas on how to begin your practice as well as advice on what doesn't does not work in terms of Scheduling patient care or time these ideas can be incorporated into your own practice model My recommendation is that you start now as you rotate with various surgeons I'm sure you've noticed the practices that seem to run very smoothly the ones with largely happy patients efficient workflows low after-hour call volume These are the practices that you'd like to emulate I would also encourage you to build relationships with office staffs in these practices so you can begin to piece together the pros and cons Establishing this relationship is also going to help facilitate referrals to your practice Ordering supplies Sometimes this is one of the most overlooked parts of preparing your practice your office manager will work with Practice management as we do in our hospital to set up vendor accounts Staples FedEx, you know for stationary lab coats You want to have all of these things set up prior to your first day in an ideal world? Supplies should be ordered prior to the practice start date That way you would have time to set up everything open the doors It is not always the case. So at least have some pens on you if Possible prior to starting your practice make sure either you or your office manager Or PPM has ordered business cards and other appointment cards and especially lab coats Building your office staff employee roles Your staff is likely to start off small with possibly just a floater or if you've already found your office manager at the start Of your practice for us. The first year was just dr Taylor and I as crazy as it may sound we did everything we suffered growing pains together and worked together to build a successful practice as The practice got busier. It became impossible for just one person to handle all the administrative tasks and answer patient calls So towards the end of our first year, we did decide to hire a medical secretary. We waited for a year Because we wanted to make sure that we established a foundation for the practice regarding office policies procedures in order to train new staff Effectively on what our vision of the practice would be We heard a medical secretary to primarily handle the phone calls schedule office visits as well as many more mundane tasks Such as faxing scanning, you know, whatever other office needs there are For a short period of time the administrative tasks were manageable the clinical work. However became very overwhelming We hired a physician assistant to help manage patient concerns see patients complete many of the day-to-day Administrative tasks such as completing disability paperwork as well as assisting in the OR For most clinical questions the PA became the point person for our office which freed up. Dr Taylor to be more effective with his time as The practice and the administrative demands grew in the office We came to the realization that we needed someone with a superior skill set to a medical secretary on the administrative side So we decided to hire a patient care coordinator. I Am sure there will be other hires in the future to help maintain our efficiency and sanity communicate with your team about staffing needs your office manager usually has great insight to the needs of the office on both ends of the Administrative and clinical side at each juncture consider having the prospective candidates meet with and be interviewed by your current office This builds a sense of responsibility respect and teamwork. That is so important to a happy and efficient office Screening patients this is a little about organizing operations You want to develop a screening process for the staff to make appointments for patients? You want to take the time to develop this process that is revisited over time While you may be willing to see almost anything to fill your hours in the first at least two You know maybe three years that will change down the road as the practice grows and Sure staff is aware of all the conditions that you will and will not treat You have to remember that while you can often tell very quickly from one to two Sentences that a patient is or is not appropriate for you to see these lines are more gray for medical secretaries without clinical experience Just like unique clinical algorithms for treating rotator cuff disease we also need algorithms for Determining if a patient is appropriate for you for the physician extender if there is one or referral to another clinician The worst thing is to back up a schedule with cervical spine when you're a shoulder surgeon Establish a referral process to utilize both physician referral service as well as a process for making internal referrals Remember that just like you try to build good relationships with colleagues to get referrals inter office staff Relationships often generate even more referrals because we are the gatekeepers to the office you Want to establish an appointment system? How long would you like your appointments to be for new patients follow-ups post-ops as well as how many of each type? Would you like to have on any given day each visit type has a different different expected duration? the major misconception by office staff is that a follow-up visit is a very quick visit because the patients already been seen previously the reality is the office the follow-up visit often takes more time than a new visit because they're often there for a surgical discussion because We haven't resolved the issue Begin creating your office Bible your office manager should create your office manual Which we call our Bible Which is going to be used throughout the practice for reference to policies procedures as well as going to be the training guide for new Staff office staff changes over time. So it's very important to continue to maintain this training guide There are other day-to-day tasks that need to be taken care of it's one of the biggest responsibilities of your office manager to create systems for these items that will keep the office organized and get the necessary daily tasks done efficiently The office is going to receive many faxes emails and requests for review of physical therapy plans completion of disability Paperwork or other paperwork that patients need to go back to their jobs The best way to tackle this is to choose one administrative day per week to review Complete and have your office staff return to the requester This way the office staff can give a specific timeline as to when the paperwork will be signed and completed Getting back to patients after they've had MRIs cat scans x-rays is the bane of everybody's existence Patient want patients want answers and they call our office sometimes a few hours after the imaging is done looking for results Creating a system to review imaging results and follow-up will greatly help your team when communicating with patients The best way that we've done. This is when the imaging is reviewed in EPIC Dr. Taylor sends us an in basket message with the next step such as having the PA to call the patient to review the results Staff to call the patient to schedule a follow-up This way the designated staff accepts responsibility of the task and the office does not have angry patients calling looking for answers You're also going to want to establish a system with your billing office early to review collections billing issues balances, etc Meeting monthly to review. These things will help you in the practice stay on top of any issues that may arise The take-home message is there is no exact blueprint for your practice It is going to be a dynamic learning process of trial and error You want to make sure that you select the right team that will set you up for the right task Make sure to keep the lines of communication with your staff open as it will build trust within your team Understand that your staff is not only an extension of you But a reflection of you to your patients and referral sources as they will interact with them greater than 90 percent of the time Most importantly we protect your time, which is your most valuable asset Make sure you are able to communicate with your patients and referral sources We protect your time which is your most valuable asset make sure You communicate personal obligations school events anniversaries birthdays so that we we can make sure that you're present for all of these things Support your staff and they will support you in our office We know every day that we're supported by our physician And this support gives our team the boost that we need to work as hard as we can to ensure that dr. Taylor's practice is successful Thank you Thanks, carrie a lot of important information on people who support you as you start your practice and then we'll move on to Similar vein that people have alluded to as well is the billing and insurance Credentialing process as you start your practice, which brian cravo will give us an overview of I think you're muted brian. Sorry Sorry Sorry about that. Thank you. Michelle. Thank you everyone for having me I wanted to touch base a little bit about billing and credentialing As it relates to working in a in a practice setting. So when we talk about credentialing It's an overarching term for both credentialing as well as enrollment And it's essentially the process that's involved in getting you to be recognized and approved Both at your local hospital as well as by the insurance carriers And it's essentially a process in which they are validating that you are who you say you are with your background with your cv your Locations your malpractice insurance your malpractice history all of that information and it's done In two different directions one by the hospital from and from a medical staff standpoint and then After that moving on to the insurance carrier side of things so on the insurance side there's a website called caqh and what that essentially does is it centralizes your Provider application to the insurance plans So it's one place that gets that all of your information is sent out to And then the insurance plans take that information and begin Pretty much that same verification process that the hospitals did to validate that you are who you say you are and uh, and that you are Worthy of being on their insurance panel As a regular ballpark, it tends to be about four to six months to get credentialed and enrolled in an insurance plan However, there are some plans to take a little bit shorter and a lot of plans to take a bit longer depending on what System you work with or what employer you work with they may have something called delegated credentialing And that's a way where they essentially send a spreadsheet over to the insurance carrier with all of your Personal information where they simply upload it into their system that speeds the credentialing process along much more And there are a whole whitney of different Abbreviations and acronyms related to enrollment. I wanted to highlight a few key ones the first and foremost being Npi because that's the bread and butter think of that almost as a social security number for you It's a 10 digit number. No matter where you go that npi number will be yours to stay Secondly is a tax id number or a tin or an ein and that's the number that's issued by the irs That you are associated with so it could be Billing under your name as a sole practitioner. It could be you as part of a group It could be you as part of a health system or hospital group You would roll up to that tax id number skipping around a little bit more, PTAN is a Medicare provider ID number. Once you enroll in Medicare, you get established an ID number, which is called a PTAN. And then jumping down a little further, NPES, N-P-P-E-S, that's essentially the NPI registry. It's Medicare's large database where they assign an NPI to you after you submit the electronic paperwork. Wanted to mention a few important things as it relates to credentialing. First and foremost, you should know who it is that is managing your CAQH profile, or you may be doing it yourself. And there's what's called re-attestation. Every four months, CAQH requires you to go in and validate that you are still practicing at the locations that you say you are practicing, and that all paperwork is up to date, your malpractice insurance base sheet, any other key information about you. It's critical that you keep re-attesting every four months or that you have a designee who is doing that, because if you don't re-attest, you will get dropped from the insurance panels. Additionally, if you change employers, particularly if you're in the same market as where you're currently practicing, oftentimes you or an office member will need to send a letter indicating that you are leaving that organization as of a certain point in time. Without doing that, it's entirely possible that the insurance carrier will begin sending checks to your old practice for your new dates of service. Additionally, if you get married and you change your name or have another reason to change your name, there are unfortunate consequences to that, because you update your name with the Social Security Administration, and then further down the line, you'll need to also update your NPI number to that name, and then subsequently your CAQH and other locations. So there are often insurance credentialing blips that come along with updating your name, because some claims may deny when the last names don't match up according to their system. When we talk about payer enrollment, that's not the same as how much you're getting paid. So you could say you're participating with Blue Cross Blue Shield, but you may be working for an employer that Blue Cross pays above and beyond their normal rates to. So just because you're enrolled doesn't mean you're getting linked to the correct rates. It's very important, especially in those first few weeks and months, that you have a team that's monitoring what's getting paid and that they're getting paid correctly. And finally, if you live in a state or in a metropolitan region that's adjacent to another state, with the advent of more and more telehealth from COVID, it's very important that you consider and you get licensed in nearby states, because telehealth rules require that you're billing according to the state that the patient is living in. So if your physical office is in New York, but the patient lives in New Jersey, you can only bill if you're licensed in New Jersey, as an example. So it's really important to keep in mind where you are licensed and where your patients are so that you can bill for telehealth. When we talk about billing, there's an overarching concept called the revenue cycle. And it's essentially all of the steps that get involved in how to get a claim paid. And it essentially starts from the moment a patient calls and wishes to schedule an appointment. And at that point, it is best that the staff members are collecting as much information in advance as possible. And the registration process is making sure that the insurance is on file correctly, that it's been validated and active when the patient arrives, that they're paying their co-pay or co-insurance up front. And then that leads to the charge capture process, where you are selecting the appropriate CPT codes, the correct ICD-10 codes, and those make their way then to whomever is doing the billing to subsequently submit claims out the door. Once the claims are submitted, then the payments come back and the billing office will post those payments. When posting payments, oftentimes the insurance carrier will deny claims or they simply will not respond in time. That's where the insurance follow-up piece begins. And billing office staff members will follow up with the insurance in order to get those claims paid. Once the claim pays by the insurance, then there's a move on to patient responsibility. Anything that has not been collected at the time of service, subsequently there are efforts to collect for the patient balances. So when taking a step back and thinking of what some of the challenges in the revenue cycle might be, a few that stick out that are worth keeping in mind. Number one is a patient may show up and present an ID card, but it's not always an up-to-date ID card. Instead, there's what's called eligibility or real-time eligibility, and that's essentially pinging the insurance plan to validate that, yes, this patient does truly have Blue Cross and that their copay is truly $35. Because sometimes if it's an out-of-date insurance card, you may miss out on the correct copay or the patient may not have that insurance any longer. Additionally, just because you're enrolled in Blue Cross Blue Shield doesn't mean you can see all Blue Cross Blue Shield patients, using Blue Cross as an example. So there's plans, there's products, there's networks, and none of those are the same. There's a PPO, there's an HMO, there are exchange products, there are commercial products, there are Medicare products. So all of those are different, and you need to know in your contract what you participate with and what you do not participate with. Because when a patient calls and says, hi, I have Blue Cross Blue Shield, that still doesn't mean you can necessarily see them. When it comes time to perform surgery on a patient, you should always go in with the assumption that a patient requires a pre-authorization for that surgery. Don't assume just because you hear that this carrier doesn't require authorization, don't assume that that's always the case. And then that leads to the next phrase that you're going to hear time and time again, which is authorization is not a guarantee of payment. What that basically means is all of the time that your office staff and you took getting this authorization approved for this patient's particular surgery could still ultimately be denied for the very same reasons that you had to fight to get them approved in the first time. It's extremely frustrating, and unfortunately, it's par for the course. Conversely, if you don't get an authorization, you're guaranteed that you're not going to get paid. When it comes to these authorizations, insurance carriers more and more are using third parties, such as OrthoNet or Epicor, to manage orthopedic surgery benefits. Their goal is very simply to not approve that case, not pay for that case. So you need to demonstrate that the case is clinically appropriate. And to that end, get familiar with and know the different CPT codes you bill, different modifiers that are available. And you need to code based on what gets documented in the op note or in the office visit note. It's not based on coding in order to get the highest reimbursement. It really needs to be reflective of what you actually performed and documented. Lastly, keep in mind that the best time to collect a patient balance is when the patient is in the office, ideally ahead of time, ahead of the surgery, ahead of the office visit. But if not, if they have a follow-up visit, make sure you have your office staff tuned in and able to collect on those balances, because that's the perfect opportunity to collect. Otherwise, it's far more laborious and cost effective and costly to collect on those patient balances when they're not physically in front of you. Final thing I wanted to touch on, and this alone could be a 20-minute discussion, is why cash could be high one month and low the next month and vice versa. There's a whole litany of reasons why payments could fluctuate on any given month. And I wanted to outline some of the key factors, one being volume. Very simply, if you had higher surgical cases one month, the subsequent month or the month after that will most likely lead to higher payments. Similarly, if you're on vacation this week, you may not feel it next week or that week, but you will feel it a month from now. Typically, it's about 30 to 60 days from getting paid, at least paid for the first round of CPT codes. Next up, the service mix. So, if you performed a number of ACLs for three months and then you switched over to shoulder surgeries, each of those have different reimbursements. So, if you're changing the types of procedures that you're performing or the types of office visits, the level of service intensity, that will affect what you're bringing in on a month-over-month basis. When it comes to payer mix shifts, depending on the market that you're in, if you have more Medicare patients, that will lead to lower reimbursement versus a commercial carrier. Or similarly, if you have a lot of workers' comp patients, oftentimes those take slow to reimburse. And payers pull lots of stunts when it comes to actually making a payment. Particularly, they will ask for medical records for every single case that is performed. So, just because you perform a case and you expect that it's going to be paid well, that doesn't mean it's going to be paid fast. Timing, when it relates to when you're submitting charges, when you're submitting your claims, is very important. I know closing out notes is a pain and it's laborious, but you can't bill unless the note is closed. So, make sure that that's being submitted and completed on a timely basis. With front-end issues, that could be anything related to making sure that the patient truly has the insurance that they present that they have. Patients that show up with a Medicare card doesn't necessarily mean they have just Medicare. More and more, we're seeing Medicare managed care plans, similar to Medicaid and Medicaid managed care plans. We had mentioned the referrals, the authorizations, all of that is critical in order to get paid. And finally, the billing office and the back-end follow-up. Is there a team that's following up on your claims? Are they staying on top of trends? Are they pointing out issues? How are they working claims? Are they attacking your highest dollar first and then going from there? Are there scenarios where payments are being made, but they're going to an incorrect address? All of those things could be impacting what you're collecting. And the key thing that I wanted to emphasize is there's really no one reason why a provider's cash may be high or low on any given month. There are all these various aspects and many times there's a 75 or an 80% rule to this, but there are always a lot of fluctuations that can occur. And it's important to keep in mind that it's very rare to be a very consistent collection process. So thank you for your time. If you have any questions, you can feel free to reach out and I'm happy to assist. Thank you. And so now I think we'll move on to a couple of questions. I don't know if everyone could turn their cameras on. We'll do kind of one general question to Drs. Carr, Carstensen, and Kasp, and then some specific questions to Kerry and Brian if anybody has any. So I think a question that always kind of when you're starting practice is what should you do beforehand? So did any of the panelists prepare anything beforehand? Did you make discharge instructions? Did you make instructions for patients? Did you make a website? Anything to make clinic or the OR run smoothly that you did beforehand that you would recommend for people starting practice this year or next year? Yeah, definitely. I mean, I've brought a lot of my note templates with me, especially if you're on Epic. So if you know what systems you're going to be using at your new hospital or your new practice, it's a little easier to bring that with you. But you can still kind of tailor those templates. I think that kind of helps and a little bit of familiarity when you start. But I think it's something that is at least when you go through your notes, you already kind of know where things are in those, so you're not starting from scratch. Yeah, I agree. I think clinic handouts, discharge instructions, all helpful. Don't get too stressed about it because chances are you won't be terribly busy clinically the first month or so. So you can always use your downtime in clinic to do that. So don't let it cut into your free time before you start. And how about the operating room? Anybody make anything kind of to make it run smoothly? I know you don't have, like you were saying, the staff's not going to be consistent. Anything that you did when you first started to introduce your people to your techniques or introduce the staff to the steps that you would recommend to help things run a little bit more smoothly as your staff changes when you start? I got there early and I kind of showed them what I did. I think before you start, like Deemer mentioned before, before you start trusting people to do, if they have no idea what you do, if you don't show them, then there's no reason you can get upset with them, right? So you need to go and show them what it is you do, how you like it done, and then know who you can kind of trust to do that and those who you can't. And again, I think I'm still, can be hands-on at times, but I think at least being available too, and I think if you're the one in there also helping move the patient, the staff recognizes that. If you're just, you know, if you walk in and the patient's prepped and draped, you just hope everything's right and then you get upset when it's not, and I think that's not really fair to the staff, but I think it's important, especially when you first start, get there early, show them what you like done, how you like it done, and you'll find they can kind of build on that. Yeah, I definitely agree. I think doing a walkthrough through the more complicated cases, ACLs, Tommy Johns, you know, literally just, you know, stay, you know, buy them dinner, buy some pizzas, do something, and just have like a drive-around, like a walkthrough, like, okay, I need this from this tray when I say this is what I need, you know, and just be very specific and kind of do like a quick five or ten-minute, you know, run-through of all the stuff you need, and because you'll be surprised, like, things that were in the tray where you trained because they just naturally put them there, but they don't come in the tray, and then you get in the middle of the case, you know, I need, like, the screwdriver in the bottom of the tray. Oh, it only comes with this one. What do you mean? Oh, they must have put that one in on their own, so you can't assume anything, so I think doing, like, a run-through is very helpful as well. And I think to prepare for cases to do right now with yourself, do you watch videos, kind of how did you prepare when you first started, when you realize that you're the only person who's accountable for this patient, and you have to, I mean, do the best job you can, and how did you prepare for cases, even the easy ones when you first started? Yeah, I'd prepare for every case, doesn't matter what it is, knee scope, carpal tunnel release, ACL, reverse total shoulder replacement, anatomic total shoulder. Yeah, I'd walk through the steps. I'd write them down if I needed to. I'd watch videos if you need to. Again, I think, like, we already mentioned this, go back to your training, right? The people you saw doing it, you know, they were good at it, and you want to kind of follow and imitate their steps because there's no reason to start trying some new technique all of a sudden, especially not during your board collection period, but it's very important to, for me at least, to feel very comfortable with what you're doing because there is no backup. There's nobody to call to come help, especially you'll find that if you, you know, you're in private practice like myself, I mean, my colleagues are not sports medicine trade, so there's no bailout to call them out if, you know, something goes wrong with graft prep or graft harvesting or anything like that, so I think it's very important that you think, what are your plans, A, B, C, and D, and having backup ideas of what you're going to do if you get into trouble. Yeah, I think that's the most important thing, in my opinion, is obviously study for the case and your plans, and, you know, I kept a notebook from fellowship with all my notes from the different attendings, and I would study that religiously, and I still reference back to it, but I think making sure you have what you need for the bailouts if something were to happen, so, you know, do I have a BTP tightrope if my back wall gets blown out? Do I have biocomposite screws if something, you know, do I have metal screws? Do I have suspensory fixation? Do I have, you know, what happens if I blow out this wall? What happens if this breaks? You know, do I have hardware removal sets? You know, so, you know, especially if you operate like I do, primarily at an ASC setting, you know, there's not a lot of stuff on the shelves there that we don't need, and so I had to kind of make a list of these are the things I might need, and, you know, crap moment, and make sure they at least had one of them on the shelf or else you're, you know, hoping that there's a rep nearby that can bring it, and that's the worst position to be in, so, you know, not only set yourself up for what you need for the primary or for if things go well, but try to anticipate, you know, what you might need if things don't go well, and make sure you have that available. Put it on the booking sheet if you have to, just so that it's available. Yeah, so sorry guys, my camera is not working, but, you know, I kind of made two lists. I made, you know, I walked like every step I would write down, and then I, of the procedure, just otherwise you're going to turn it over in your head a million times, and you're never going to be able to sort of sleep if you're thinking about a case. Just write it down. You know all the steps, and two, at the exact same time, I would make a list of everything I need, so I have just like this giant Google Drive folder of day of pick lists, which basically I send them at the beginning of the week of everything I'm going to need for the case from, you know, the type of table to what I prep with to what I'm closing with, just so that everybody knows that they need to have that stuff around, and so there's that combination of both writing down every single step of what I'm going to do allows me to think about those things, and then I write a list of everything that I need to have, and so early on it was painful, but now I have this giant repository of what do I need for my standard cuff repair that has all my bailout stuff, you know, have XYZ available. So a question for Carrie, so people that are like me have never hired anybody before, kind of had to evaluate office staff, so any tips on how to evaluate somebody who's interviewing for your office manager job, or for an office assistant job, and kind of what you look for them, and do you look for somebody with experience, or somebody with a specific background that you think would be successful to help a new physician in their early practice? Definitely somebody with some medical background, you know, you want to be able to grow with this person, and you want to be able to be, you know, communicate with them, and you know, let them know your needs instead of kind of having them walk in, and you know, with 10 or 15 years experience, and taking over your practice, and you know, you're kind of getting lost in the shuffle a little bit, you know, so when I started with Dr. Taylor, I had zero experience in orthopedics. I'd actually worked in behavioral health before, so you know, a lot of the practice stuff I learned along the way, the clinical stuff, which worked out well for us. And then just a question for Brian, any recommendations on how to get some experience with billing and coding for the new physician, because there's not as much emphasis on that in residency and fellowship training, although I think it's becoming more of a focus point, because we realize that you use it every single day as a physician, so any tips or courses that you recommend that a new physician can take? Sure, a few things off the top of my head. Number one, AAOS has what they call CodeX. It's a web-based tool that can be used. Similarly, Optum has a product called Encoder Pro. The AMA publishes CPT books. Unfortunately, sometimes it's just a matter of taking the book and reading through and figuring out. Surgeries tend to begin with the number two and take it from there. When it comes to billing and collections, my personal bible is a book called, from Elizabeth Hancock, and it's called The Physician Billing Process, The Potholes on the Way to Getting Paid. And it's a fantastic resource. It really talks soup to nuts about what it means to bill and collect and all the various ways you can look at receivable and every step of the process. So that would be my recommendation, The Physician Billing Process, and The Potholes on the Way to Getting Paid. Great. So it's 8.20, so I think we're probably nearing the end. Any final words of wisdom from our panelists or any final questions from any of the attendees tonight? I think it's just important that everybody knows that no matter what practice setting you're in, it's always a struggle. Those first couple of years are a struggle, and you're doing a lot of stuff that you're not comfortable with. And I'm dealing with some billing and admin stuff that I never thought I would deal with, but you know, that's just the way practice runs, and you're doing a lot of stuff you're not always comfortable with. I'll speak for myself, but also the panelists. Anybody who's listening, you just gained six new people to ask questions from. So feel free to email us or reach out to us if you have any questions about starting practice. I'm in it now, and everybody on the call has a lot of experience starting a practice and being successful. So feel free to reach out with questions, and I appreciate everybody tuning in, and a great thank you to our panelists for all of their expertise and presentations tonight. Yes, thank you so much to all of our speakers, all of our presenters for your time and expertise, and thank you all of you for joining us tonight. This webinar is eligible for CME, and you can claim it by going to education.sportsmed.org, logging in, and then clicking my resources in the webinar title. This webinar is being recorded, and the recording will be available tomorrow for you to view at your convenience. If you want to look back at coding or insurance, we understand. You'll also get an email in 24 hours with this information, so you don't need to remember it all now. Thank you again for joining us, and thank you again to our speakers and Dr. Q. You all have a great night. Thank you, everybody.

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