Anesthesia Business Consultants: Communique winter10


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Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.

Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.

ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.

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Anesthesia Business Consultants: Communique winter10

  1. 1. WINTER2010VOLUME14,ISSUE5 ANESTHESIA BUSINESSCONSULTANTS Customer service is a frequently heard buzz word, the “culture” many ad- vocate, and, in the final analysis, the true demonstration of “walking the talk”. Some will differ on whom they identify as their “customer” – for some anesthesia providers the response is often “the surgeon,” while most acknowl- edge their customer base includes a variety of individuals and organizations – patients, surgeons and proceduralists, hospital and health system administra- tors, surgery center directors, vendors, and members of the payor community. I submit that all of those listed and any others you interact with are “your cus- tomers” – they are whom you serve. The key is whether these customers view your practice as customer friendly? To better understand how your cus- tomers would rate your group’s customer service begins with a baseline assessment as to whether you and your colleagues are viewed as demonstrating a high level of customer service. ABC offers The Communiqué in electronic format Anesthesia Business Consultants, LLC (ABC) is happy to provide The Communiqué electronically as well as the regular printed version. The Communiqué continues to feature articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators. We look forward to providing you with many more years of compliance, coding and practice management news through The Communiqué and our weekly e-mail alerts. Please log on to ABC’s web site at and click the link to view the electronic version of The Communiqué online. To be put on the automated email notification list, please send your email address to ➤ INSIDE THIS ISSUE: A Culture of Customer serviCe . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Customer Satisfaction: A Necessary Element For Group Success . . . . . 2 Customer Service Makes the World Go ’Round . . . . . . . . . . . . . . . . . . . 9 Customer Service in Anesthesia Care . . . . . . . . . . . . . . . . . . . . . . . . . 12 Distinctive Client Service: Five Practices You Can Implement Today . . 15 Traditional IRA: Shall I Convert?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Breach Notification Final Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 The Stark Law’s In-Office Ancillary Services Exception: In-Office Ancillary Arrangements Remain Viable for Pain Management Practices . . . . . . . . 22 6th Circuit Federal Court of Appeals Affirms Conviction of Pain Management Physician for Overutilization & Billing Fraud . . . . . . . . 25 Perspectives on Client Service From ABC Senior Staff . . . . . . . . . . . . 26 Event Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Continued on page 6 A Culture of Customer serviCe Marshall M. Baker, MS, FACMPE Physician Advisory Services, Inc., Boise, ID
  2. 2. the Communiqué Winter 2010 PAge 3 transferable to your world — just 99%. If you were running a store, it would be obvious, should you take the time to watch, what your employees are doing. You could see them on the floor and observe their interactions, or non- interactions, with customers. Granted, it’s a bit harder to watch your fellow partners or shareholders and your employed and subcontracted physicians and other staff members. But it is possible. And, what they are doing might just be destroying the future of your practice. multiple problems + few direCt ComplAints = biG problem for you It’s no secret that disgruntled customers tell stories of their poor experiences and that this results in loss of business. In fact, a study conducted in 2006 by the Wharton School of Business and the Verde Group provides proof of this long-held general belief. According to the study, which looked at retail customers,only 6% of disgruntled customers made a direct complaint. But 31% of disgruntled customers told their friends, family or colleagues what happened. And then those other people repeated the story, multiplying its effect. Altogether, the “Retail Customer Satisfaction Study 2006” found that for every 100 customers with a bad experience, a company stands to lose 32 to 36 current or potential customers. multiple Customers And multiple points of ContACt In the retail world it’s easy to identify your customer. It’s a bit more complicated in yours. Anesthesia group “customer” interactions involve multiple interested third parties and multiple points of contact. There’sthepatientandsometimes the family and other influencers.There are the surgeons, nursing and other technical personnel, hospital administration, the medical staff, and third party payors. As to each of the customers, the number of points of contact vary from the single instance to the continual stream. And, to complicate things, in some cases the expectations of one customer group negatively impact upon another. Take, for instance, the example of case turnover time. Surgeons don’t want to “waste time” between their consecutive cases, but pressuring anesthesiologists to pick up the pace might adversely affect immediate post-surgical patient care (a key customer service factor if there ever was one) as well as the pre-surgical interaction between the anesthesiologist and the subsequent patient. settinG the stAGe for the Customer’s GreAt experienCe And for your GreAt future The first step in the solution may be the hardest: Stop kidding yourself that the delivery of expert, even world- class, medical care is sufficient to guarantee your group’s future. An “A” in anesthesiology does not automatically equate to even a “C” in customer service. Expertise from an anesthesiologist is simply expected; it’s just the down payment on your future. Expertise must consistently be supported with extraordinary customer service in order to guarantee that you will thrive. Of course, this begs the question of what great customer service is. On one level customer expectations are simple to discern: Customers want to be treated with respect, they want you to be courteous, they want you to listen to them (really listen to them) and to respond fully to their questions and concerns. They want you to be friendly, they want you to smile, they want you to say please and thank you, they want you to show up on time and they want you to follow through with what you say you will do. In addition to those common expectations (which are often forgotten in terms of delivery) you must identify the specifics of ideal customer service at your institution, not through your eyes, but through the eyes of your customers. As the study discussed above reveals, you can’t do this simply by relying on Continued on page 4
  3. 3. The Communiqué Winter 2010 Page 4 Customer Satisfaction: A Necessary Element For Group Success Continued from page 3 complaints that have been brought to your attention, as only a small percentage of disgruntled customers will have ever informed you of the problems. Certainly, you can conduct formal or informalsurveysof yourpatients,surgeons and other customer service touch points. In fact, as your group begins to excel in customer service, surveys, especially those that reveal high patient satisfaction levels, have the benefit of not only spurring you on to even higher levels of performance, they become an important tool for leverage in the larger context of group/ hospital relations. But to begin, I suggest that you take a more practical, “down and dirty” approach: draw on your own knowledge base — not only as physicians in terms of how you value the interactions your colleagues have with you, but also with respect to the interactions you have had with your physicians when you have been a patient as well as your interactions with retail and wholesale establishments, both in regards to products and services. Ideally, you are aiming at creating what I term an “experience monopoly” for your customers: an experience of such a high quality that your customers would not consider obtaining it from any other source. Don’t attempt to “benchmark” to other physician groups; instead, if you must benchmark at all, aim to compete with the Four Seasons or the Ritz-Carlton in terms of the experience that they provide. To illustrate, let me provide you with two examples related to the anesthesia world, one directly, and the other tangentially, that describe this concept of experience monopoly: In the late 1980s, I had minor outpatient surgery at a world-class hospital. More than 20 years later I recall the experience clearly. From a technical standpoint, the anesthesiologist must have been an expert: I felt no pain, had no complications and was back at work the next day. But, shortly after the physician introduced himself to me in the pre-op area he walked a few feet away to make a phone call: several minutes of screaming at his divorce lawyer about his soon-to- be ex-wife, whom he did not describe in particularly endearing terms. He was so visibly upset that I wondered about his ability to concentrate on my care. Despite the fact that everything went smoothly, I would never consider having another procedure performed at that facility. Contrast that with the following experience: A few years ago, immediately after checking out of the Hilton Tapatio Cliffs Resort following speaking at the ASA’s Conference on Practice Management, I met Chester Haymore, the bellman. Chester greeted me warmly, just as he did each and every person who passed him. He asked each person waiting at the hotel’s entrance if he could help them. He offered chilled bottles of water and suggested that people wait in the shade.
  4. 4. The Communiqué Winter 2010 Page 5 He quickly summoned cabs or town cars and arranged for valet parked cars. He loaded luggage into trunks and helped people into cars. He told a particularly tall man that he would adjust the seat in his rental car. When he overheard a man comment that he had cut his finger, Chester asked if he needed a band-aid! Chester isn’t just a bellman, he is a one-man customer service king with a mission. He elevated the entire experience of the hotel, which otherwise was a slightly aging, unmemorable place. 1 Once you’ve examined your knowledge base of customer service experiences, my advice is that you look at each possible interaction between the members of your group and your customersanddeviseasetof expectations. I’m not talking about setting hard and fast rules for all conduct, as we’re talking about professionals and, in any event, you do not want to institute robot-like performance. However, there should be minimum expectations and those minimums should not simply be aimed at meeting minimum levels of customer satisfaction, but, rather, at hitting high levels of service that will delight the customer. Next, you need to document your group’s customer service expectations and train your group, both physicians and other staff, in exceeding them. Importantly, you need to incentivize, both financially and socially, your group to take customer satisfaction expectations seriously. This means that your group’s compensation plan must take into account customer service factors in determining total compensation. It also means adopting a plan for the recognition of service excellence. In order to accomplish these goals, you must coordinate your customer service plan with, and into, the provisions of your group’s organizational documents, subcontracts, employment agreements, and compensation plans. For example, if your partnership agreement and employment agreement simply reward production, providing no incentive for better customer service, then you have abandoned the legitimate right to claim to be shocked when your group’s physicians rush for volume, even with an eye to patient care standards, but ignore the quality of customer interaction, only to have complaints, reported or unreported, destroy the foundation of your practice. Addressing this issue as far as your physicians go is only a part of the process. You must take similar steps with any support and office personnel who come into contact with any identified customers. This extends to the employees of your billing service provider – one cranky interaction can destroy the improvement that your group, internally, has worked to achieve. Your contracts with, and policies adopted in respect of, these entities and individuals must support those requirements and provide for penalties in the event of breach. Why Care? Why do you need to care about customer service when your group has the exclusive contract at the hospital? After all, your customers can’t go anyplace else. Because customer service is directly related to customer satisfaction which is directly related to support from the medical staff and from administration. That support is essential in respect of renewing your exclusive contract and in obtaining necessary financial support from the hospital. Sure, you may be the only game in town, but if you don’t pay attention to customer service, someone else will be the next only game in town. 1 It’s telling that when I wrote a letter to the Hilton following my stay recommending that they make Mr. Haymore their chain’s customer service excellence evangelist, I didn’t even receive a form letter in response. Of course, Mr. Haymore, whom I copied on the letter, called me to express his sincere gratitude. Mark F. Weiss is an attorney who specializes in the businessandlegalissues affecting anesthesia and other physician groups. He holds an appointment as clinical assistant professor of anesthesiology at USC’s Keck School of Medicine and practices nationally with the Advisory Law Group, a firm with offices in Los Angeles and Santa Barbara, Calif. Mr. Weiss provides complimentary educational materials to our readers. He can be reached by email at
  5. 5. The Communiqué Winter 2010 Page 6 A Culture of Customer Service What is the level of satisfaction your customers have with your services? Satisfaction surveying is encouraged and, while approaches vary, the goal is to better understand how you and your group are viewed (and rated). Surveying techniques include telephone, focus group, written question- naires, and the disciplined recording of “feedback” as it is received. Some types of “satisfaction surveying” include: • Patient Satisfaction (with the experi- ence with their anesthesia provider) • Surgeon/Proceduralist Satisfaction (with your service, responsiveness) • Staff Satisfaction (both anesthesia group and delivery site (hospital, ASC, Endoscopy Center, birthing center, etc.) – about their experiences work- ing with you (as clinical support or administrative support staff for you) • Payors (what’s the “temperature of the water” when you or your staff interact with payors and their staff?) Assessment is one tool that will pro- duce information to either reenforce that a high level of satisfaction exists, or alert you to areas (and individuals) where there are opportunities for improvement. Examples of surgeon and patient satisfaction surveys appear on pages 7 and 8. In addition to “after the experience” satisfaction surveying, customer service initiatives should be proactive. Here there are a variety of actions or initiatives the group might consider to build a loyal and supportive following. Two that I found produced positive results: (1) The anesthesiology group I was as- sociated with instituted a “thank you card” program – our anesthesia providers would leave a card at the patient’s bedside when making post-op/post-procedure rounds. The card read: THANK YOU for allowing us to be of service to you. We are committed to a healthy community. If you have questions about the care we provided – call: XXX-XXXX If you have questions about payment of our charges – call: YYY-YYYY Anesthesia Consultants, PC The key here was two-fold, to genu- inely thank the patient and to reinforce that we had been involved in their care – patients always remember their sur- geon/proceduralist; but seldom recall the name of their anesthesia provider or the group that provided the anesthesia. In fact, many challenge the charges when re- ceived and it’s not uncommon to receive a call with the patient stating, “I never saw that doctor”. The card (with the anesthe- sia provider’s business card enclosed) can minimize those types of calls. (2) Another proactive approach we took was the recognition of every surgeon’s birthday – sending a card and a small gift (e.g. – one year it was a mag-lite flashlight, another a small tool kit, with our logo em- blazoned on the item). First, the surgeons were impressed – one remarking, “my mother doesn’t even remember my birthday”. But the really positive result was when we were battling with insurance companies for payment for post-op pain management and consultation, and the payors threat- ened to reduce the surgeon’s allowable charge to pay for pain management. The surgeons rose to our defense (a new behavior in our community where re- lationships between anesthesiologists and surgeons often disrespect). Because of our positive relationship building activities (only one of which was the birthday gift), they advised the payors that requesting a “pain specialist” for their patient was no different than requesting a consult from any other sub-specialist, and such consul- tation and service was NOT a part of the surgical or procedural event. Beyond surveying, cards, or gifts the theme you want to communicate to your customers is the way you and your col- leagues treat people. When there is an inappropriate behav- ior, how does your practice address it? Like all communication, it is how the individual interprets your words or ac- tions; and whether such disruptive and inappropriate behavior is viewed as such by you as well as by the customer. Paramount to such a disruptive or in- appropriate behavior is how your group responds. Is such behavior allowed to continue without intervention? I would suggest a NO tolerance policy for outbursts,“scream-fests”, or deliberate disregard for “driving outside the lines” of established group culture and behavior. The development of a disruptive behav- ior protocol will be important to assure there is no misunderstanding about what is expected. When an event occurs, there must be immediate action, and a process to coach the individual toward a change in behavior, with understanding of the consequences if there is no demonstrated change and improvement. To ignore these types of misbehaviors can result in a potential loss of business, damage to the group’s reputa- tion, or worse, litigation. Customer service should be a hallmark for your practice, and taking the time to craft a customer service program and in- still a culture that is readily recognized as “customer friendly” for your organization will be a cornerstone to the long term suc- cess of your practice. Continued from page 1 Mr. Baker is an experienced health- care executive, administrator, educa- tor, and consultant. His practice focuses on strategic position- ing; compensation design; practice struc- ture/formation; and management and governance structure. He is a Past President of Ohio MGMA, New Mexico MGMA, the American College of Medical Practice Executives, Ambulatory Surgery Center Assembly (MGMA), and the New Mexico Heart Institute. He may be reached at 208-577-8869 or
  6. 6. The Communiqué Winter 2010 Page 7 Please indicate your response to the following questions: Yes No N/A 1. Do your patients undergo appropriate pre-operative evaluation? 2. Are you routinely informed if a patient has not been cleared for surgery due to medical reasons? 3. Is the reason for cancellation or delay appropriately communicated to you? 4. Do you feel that our physicians are helpful in facilitating pre-operative clearance for surgery? 5. Are you satisfied with the quality of care provided by the anesthesiologists in the Anesthesia Service? 6. Do you believe that our physicians provide good care for your complex and sick patients? 7. Are you pleased with the level of technical expertise (i.e., regional blocks, intubations, invasive monitoring) practiced by our physicians? 8. Do you believe that our anesthesiologists offer an appropriate range of subspecialized anesthesia expertise (i.e., outpatient, pain management, etc.)? 9. Do you believe that subspecialized care benefits your patients? 10. Does the Anesthesiologist communicate appropriately with you concerning any problems during the case and the conditions of your patients at the end of surgery? 11. Does the Anesthesiologist provide appropriate and timely care to your patients post-operatively in the recovery room (i.e., pain management, respiratory or cardiac difficulties)? 12. Do our physicians communicate appropriately with you concerning problems encountered by your patients in the recovery room? 13. Does the Anesthesiologist treat you, your patients and their families in a courteous and professional manner? 14. If you need to contact an Anesthesiologist, is their response accomplished in a timely and appropriate manner? 15. Overall, are you satisfied with Anesthesiologists’ clinical care, technical skills, responsiveness and professionalism? 16. Would you continue to utilize the services of our Anesthesiologists over those of other anesthesia groups if the anesthesia service operated under an “open staff” model? 17. Do you have any suggestions for our practice? Comments: 18. Overall, how would you rate our current Anesthesiologist’s clinical practice and service level? On a 1 - 5 scale, with 5 being the highest rating? Surgical Staff Evaluation of Anesthesia Services In an effort to monitor how the Medical Staff perceives the anesthesia services provided by__________________________________ Anesthesiology and Pain Management, we would appreciate your completing this survey and returning it in the enclosed stamped appropriate manner? 15. Overall, are you satisfied with Anesthesiologists’ clinical care, technical skills, responsiveness and professionalism? 16. Would you continue to utilize the services of our Anesthesiologists over those of other anesthesia groups if the anesthesia service operated under an “open staff” model? 17. Do you have any suggestions for our practice? Comments: 18. Overall, how would you rate our current Anesthesiologist’s clinical practice and service level? On a 1 - 5 scale, with 5 being the highest rating? Surgical Staff Evaluation of Anesthesia Services In an effort to monitor how the Medical Staff perceives the anesthesia services provided by__________________________________ Anesthesiology and Pain Management, we would appreciate your completing this survey and returning it in the enclosed stamped envelope. POST ANESTHESIA SURVEY FOR PATIENTS PATIENT’S NAME (Optional) ____________________________________________________________________________________ DATE of surgery/procedure _____________________________________ HOSPITAL/ASC ________________________________ TYPE OF SURGERY/ PROCEDURE ________________________________________________________________________________ ___________________________________________________________________________________________________________ Please “mark” the appropriate response below. 1. Before your surgery/procedure, did you speak to an anesthesiologist/nurse anesthetist? Yes  No  If yes, were you satisfied with the courtesies extended by this anesthesia provider?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent Did he/she explain your anesthetic in terms you could understand to your satisfaction?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 2. Were you informed to your satisfaction of what to expect BEFORE your surgery/procedure?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent a. Were you informed to your satisfaction of what to expect DURING your surgery/procedure?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent b. Were you informed to your satisfaction of what to expect AFTER your surgery/procedure?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 3. Was the “start” of your anesthetic satisfactory?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 4. How was your stay in the Recovery Room (Post Anesthesia Care Unit – PACU)?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 5. Please explain any problems associated with your anesthetic: ______________________________________________________ ________________________________________________________________________________________________________ 6. What was the best thing about your anesthetic: _________________________________________________________________ 7. Overall, how would you rate the anesthesia we provided for you?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent Example of a Surgeon and Patient Satisfaction Survey (Courtesy of Mr. Baker)
  7. 7. The Communiqué Winter 2010 Page 8 Example of a Surgeon and Patient Satisfaction Survey (Courtesy of Mr. Baker) 18. Overall, how would you rate our current Anesthesiologist’s clinical practice and service level? On a 1 - 5 scale, with 5 being the highest rating? Surgical Staff Evaluation of Anesthesia Services In an effort to monitor how the Medical Staff perceives the anesthesia services provided by__________________________________ Anesthesiology and Pain Management, we would appreciate your completing this survey and returning it in the enclosed stamped envelope. POST ANESTHESIA SURVEY FOR PATIENTS PATIENT’S NAME (Optional) ____________________________________________________________________________________ DATE of surgery/procedure _____________________________________ HOSPITAL/ASC ________________________________ TYPE OF SURGERY/ PROCEDURE ________________________________________________________________________________ ___________________________________________________________________________________________________________ Please “mark” the appropriate response below. 1. Before your surgery/procedure, did you speak to an anesthesiologist/nurse anesthetist? Yes  No  If yes, were you satisfied with the courtesies extended by this anesthesia provider?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent Did he/she explain your anesthetic in terms you could understand to your satisfaction?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 2. Were you informed to your satisfaction of what to expect BEFORE your surgery/procedure?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent a. Were you informed to your satisfaction of what to expect DURING your surgery/procedure?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent b. Were you informed to your satisfaction of what to expect AFTER your surgery/procedure?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 3. Was the “start” of your anesthetic satisfactory?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 4. How was your stay in the Recovery Room (Post Anesthesia Care Unit – PACU)?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 5. Please explain any problems associated with your anesthetic: ______________________________________________________ ________________________________________________________________________________________________________ 6. What was the best thing about your anesthetic: _________________________________________________________________ 7. Overall, how would you rate the anesthesia we provided for you?  1) Very Dissatisfied  2) Dissatisfied  3) Satisfied  4) Very Satisfied  5) Excellent 8. Please give us your suggestions for improving the care we provide to patients: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________
  8. 8. the Communiqué Winter 2010 PAge 9 Well, even if it does not necessarily make the world go ’round, good customer service certainly makes the journey less bumpy. We can all easily identify poor customer service – just think back to the lastbadexperienceinastoreorrestaurant. Defining what comprises good customer service is a much more difficult task. Most agree that customer service is an organization’s ability to meet their customers’ wants and needs. However, many believe that good customer service is an organization’s ability to constantly and consistently exceed the needs of their customers. Though our customers’ expectations and needs may differ according to our fields of service, the general rules of good customer service pertain to all of us. As I was preparing to write this article, I asked personnel in different areas of our office two questions: “Who do you consider to be your customers?” and “What do you do to provide them with good customer service?” I then analyzed their answers, incorporated them into my current research and arrived at the following common elements of good customer service: • Be available – This element covers everything from answering your phone to returning emails. Customers want to be heard. Customers desire to reach a human being when they are trying to make contact with your organization. If at all possible, phone messages and emails should be returned within 24 hours – even if it is just to let the customer know that their message was received. • Listen – Focus on what the customer is saying to you, be attentive, and show that you are listening to them by responding appropriately. Ask questions in order to understand their wishes and carefully listen to their answers to make sure you are meeting their needs. • Keep your promises – Before you make any promises or commitments to a customer, make sure you can fulfill them. Keep appointments and meet deadlines. Being reliable is a key element to excellent customer service. • Manage expectations – Many times what is perceived as poor customer service is simply a disappointed customer whose expectations were not met. This can be avoided by managing the customer’s expectations in order to have them match what you are able to deliver. Reiterate what you understand to be your commitment prior to completing the encounter with your customer. Your goal should be to exceed your customer’s expectations. • Make customers feel important and appreciated – Customers are very sensitive and can sense whether you really care about them. Use their name (though not excessively) and take every opportunity to thank them for their confidence in you and for the opportunity to serve them. • Be honest and sincere – Do not take advantage of your customers. Be truthful and keep what is in the best interest of the customer as your goal. People value honesty, integrity and sincerity and these traits engender confidence in you. Customers like dealing with people they can trust. • Address complaints quickly – Nothing can ruin a positive customer service experience more than a complaint that is perceived to be ignored. Acknowledge a complaint as soon as possible and let the customer know that it is being addressed. If the customer is upset or angry, calm them with words and actions Customer serviCe mAkes the world Go ’round Marie Walton, CMPE Vice-President, Client Services iMed Group, Houston, TX President-Elect, MGMA-AAA Continued on page 10
  9. 9. the Communiqué Winter 2010 PAge 10 that show you take their complaint seriously. Once the customer is satisfied that their complaint is being addressed,make sure you thank them for bringing the problem to your attention. Let the customer know what you have done to resolve their complaint. Complaints should be viewed as opportunities to improve processes, policies and procedures. • The customer is always right – While they may not technically be right, the customer believes that they are right. It is important to remember this when communicating with them and to avoid implying that they are wrong. • Know how to apologize – When something goes wrong, apologize. Customers appreciate it, it is a simple thing to do, and it can defuse a potentially damaging situation. • Be helpful – Assisting someone, even if it is not your job or will not reap you immediate benefits, can be a sure way of keeping existing or acquiring new customers. Help your customers understand terms and processes inherent to your organization. • Go the extra mile – If you want to provide excellent customer service, make that extra effort. Do not just tell the customer who can help them, offer to contact them on the customer’s behalf. Customers notice when people make the extra effort. • Use the power of “yes” – Always look for opportunities to accede to a request. Even when the answer is “no,” find a way to not have to say so directly. If possible, let the “no” decision be made by an entity other than your organization. Even if you already know that the answer to the customer’s request will be “no,” offer to inquire on their behalf and then let the customer know that the other party has denied their request. After all, there is always the possibility that something has changed and the answer will be “yes.” • Train your staff often – Many people think customer service is instinctive but good customer service needs to be taught. Talk about what good customer service is and go over examples of both good and bad customer service and point out the differences. Use complaints you have received as teaching opportunities. Have your staff demonstrate good and bad customer service through scenarios or skits. Provide your staff with sufficient information and empower them to be able to make decisions that lead to excellent customer service. Your staff needs to be as concerned about your customers as you are. The final element of good customer service does not directly relate to customers but it is an integral part of an organization’s success in exceeding the customer’s wants and needs. • Treat your employees well – Employees are your internal customersandneedtobeappreciated. Treat them with respect, thank them, let them know how important they are to you and they will treat your customers in a similar manner. Regardless of what responsibilities you have within your organization, you can apply these elements of customer service to improve your customers’ experiences. First, determine who your customer is, and then determine the process by which your organization can deliver its services or products in a way that allows the customer to access them in the most efficient, fair, cost effective, and humanly satisfying and pleasurable manner possible. Thus, you will be providing excellent customer service. Additional training tools and information on this subject may be found in the Medical Group Management Association (MGMA) website at www. by entering “customer service” in the search box. Marie Walton, CMPE is Vice-President for Client Services of iMed Group, a medical practice management company where she has worked for almost 10 years. Currently, she serves as President- Elect of the Medical Group Management Association Anesthesia Administration Assembly (MGMA-AAA). She has made many anesthesia business presentations for MGMA-AAA and Anesthesia Administrators of Texas(AAT). Ms.Waltonmaybecontacted at Customer serviCe mAkes the world Go ’round Continued from page 9
  10. 10. The Communiqué Winter 2010 Page 11 Mr. Baker kindly provided the model employee code of conduct below, offering a direct means of drawing anesthesia group personnel’s attention to specific components of the excellent customer service discussed in Ms. Walton’s article on page 10. Customer Service Code of Conduct As an employee of “medical group name”, I agree to abide by the following code of conduct. I will always remember that we are in the healing business. Many of our patients come to us not feeling well and they have a right to expect us to do everything in our power to help them. We may not be able to fix their problem, but we must make doubly sure that we are always compassionate and gracious to them. Professional behavior is demonstrated by the following actions. I will always take responsibility for my own actions. I will not blame others or make excuses. If I have a bad day at home that is no excuse for me to come to work and take it out on others. The true test of a person’s character is not how they act when everything is going great, but how they act when nothing is going great. I will use “please” and “thank you” as much as possible when asking a patient or staff to do something. For example, “please sign in, please step on the scale for me, Thank you for coming today.” If my provider is running more than ½ hour late I will apologize to the patient for the delay. For example,“Ms. Smith, thank you for your patience, I apologize for the delay in seeing you.” If I room a patient, I will check back with them within 15 minutes if my provider has not seen them yet. I will address a patient formally by their first and last name or last name when calling them to the back. I will wear my nametag and smile and introduce myself to each patient (For example, “good morning Ms. Smith, my name is Betty, please come this way.”) I will look a patient in the eye when speaking with her. I will not shout at a patient or staff member, whether calling them to the front desk or announcing their name in the waiting room. I will not shout down a hallway. I will keep my voice at a conversational level when talking with patients or other staff. I will not engage in loud conversation, laughing or virtual communication with anyone in the presence of patients. I will not use cell phones either verbally or by texting during work hours. I will always do my job to the best of my ability. If I am aware of a problem or issue I will take ownership and address the matter until resolved or until a physician or management reassigns responsibility. I will not say “I can’t help you.” I may not be personally able to solve a problem but I will seek out someone who can. I will not waste company time, but will take care of my own responsibilities efficiently and effectively, and if I am not busy I will inform management or I will volunteer to assist others. I will dress appropriately and be well groomed. I acknowledge that my speech and appearance make an impression on patients and I want the impression to be positive. I will always treat patients and staff, regardless of circumstances, the way I would like to be treated. I agree to abide by the“medical group name’s”Customer Service Code of Conduct. Employee Signature _____________________________________________________________ Date _______________
  11. 11. In the current economic environment it is not enough that anesthesia practices have consistently good outcomes from the care their practitioners provide. It is a given that today’s anesthesia providers can successfully manage any surgical patient safely, no matter how complicated the circumstances or medical history, through surgery and post-operative recovery. This is the basic service that anesthesia groups sell and that hospitals and surgi-centers buy. What matters is not just how well the anesthesia practice manages the patients’ surgicalexperience,but,ratherhowwellthe practice manages the broader expectations of its various customers. Anesthesia has become a critical cog in a much larger system. As such, the success or failure of the relationship depends not only on its ability to anticipate the needs of individual patients, but also on its ability to anticipate the needs of the system as a whole. This is why customer service has become one of the most important anesthesia practice management issues of the day. Anesthesia training programs do an excellent job of preparing anesthesia providers for the exigencies of surgical and obstetric anesthesia. Most anesthetics take the provider through a familiar routine of preparation, induction, maintenance, emergenceandrecovery. Rareistheclinical situation that the provider has not already worked through at least a few times or where the fundamental physiological and pharmacological issues are not familiar. The operating room and the delivery suite are environments in which expectations and requirements are, for the most part, well understood and readily attainable. There is ample evidence of most providers’ ability to artfully manage the needs of patient and surgeon. Consistently reliable feedback of an array of monitors allows for timely and tactical decision-making. With experience comes confidence. Real challenge occurs when these same clinicians step outside the operating room into an environment in which they have neither the same type of reliable feedback nor the experience to consistently juggle a seemingly inconsistent and conflicting set of expectations and requirements. Marketing consultants love to ask who is your customer and what does your customer want? Not only are these tough questions to answer in anesthesia, but no two sets of answers will be the same. Too often the default answer is “it depends,” which does not really allow for effective decision-making.Ifcustomerrequirements cannot be clarified and quantified, service delivery strategies cannot be formulated and refined. While the same basic assessment and decision-making skills that make clinicians so effective in the operating room will actually serve them well in the Board room,the application of the concept is not always clear in an unfamiliar context. Anesthesia providers are trained to accept and rely on digital arrays that indicate how the patient is responding to anesthetic agents administered during the case, while the absence of such reliable monitoring tools and feedback outside the operating room makes for confusion and distrust. It may take some training, but anesthesia providers must learn to be able to read their customers like their monitors. There is no doubt that this is often more art than science, but it is not less important a skill. Herein lies both the greatest single opportunity and quintessential test for the anesthesia provider. Anesthesia’s value to the system is that anesthesia providers do moretodeterminetheoverallqualityof the the Communiqué Winter 2010 PAge 12 Customer serviCe in AnesthesiA CAre By Jody Locke ABC Vice-President of Anesthesia and Pain Management Services
  12. 12. The Communiqué Winter 2010 Page 13 patient’s surgical or obstetric experience than any other provider involved in the surgical experience. Because customer service is about perception, though, if I do not understand or appreciate how you are going to anticipate my every need and guide me safely and artfully through the potential trauma and stress of my surgery, then all your training and skill is for naught. Surveys have shown that two areas of greatest concern to hospital administrators with regard to their anesthesia providers have to do with outlier providers and pre- operative communications. Too many groups suffer the consequences of their own inability to monitor and manage their problem providers. It is a curious phenomenon. So much is at stake and yet when it comes to monitoring how different members of the department or group interface with patients and other members of the medical staff there is an unfortunate and, sometimes, fatal tendency to turn a blind eye. There is a fine line between the competence of a clinician who can listen to and evaluate the situation of a patient effectively and in a way that the patient is left with a sense that he or she is in good and competent hands, and the arrogance of the scientist who does not appear to need or want the input of the patient. In other words, today’s patients want what they get in the salon; they want to be cared for and not just taken care of. We all know good customer service when we experience it. Some intangible quality bonds us to certain service providers, even though we may know they are not the best providers or the cheapest option. Research suggests it is not the relationships where nothing goes wrong that are the strongest, but the ones where the commitment of the provider to find solutions and keep the relationship are evident. If your mechanic does not fix a problem with your car the first time, you may be upset but you will give him the chancetosolvetheproblem.If theproblem is resolved then your stock in him goes up but if he does not demonstrate an attitude of caring, compassion and contrition you will not go back. The reality of today’s increasingly complicated reliance on technology is that not all solutions are evident or easily identifiable. This is especially true of medicine. A hospital is a forum for collaborative problem-solving where teams of providers and administrators work in partnership to achieve two related goals: higher quality care and stronger balance sheets. It is normally assumed that if they accomplish the first, the second will follow. Given the vagaries of the market, however, there is not always a clear connection between the two and sometimes the latter supersedes the former. Eachofthefollowingfivestakeholder’s perspectives on the surgical experience is defined by his or her own requirements, expectations and history. It is not unlike the parable of the blind men and the elephant. Each one sees the relationship only from his or her perspective. Typically, none of the participants is willing to look at the relationship through any other lens. It is easy to see why anesthesia providers become so exasperated with their interactions in the operating room suite; no one else sees what they see. • Patients want amnesia and the confidence that they will be pain- free and safe. • Surgeons want availability so that they can get their cases done in a manner that allows them to be productive • Hospital administrators want affordability because they are always struggling with the bottom line • The Operating Room staff and the nurses, by contrast, want affability because they have to deal with a variety of personalities and complex clinical situations • Meanwhile the members of the anesthesia department or group want acknowledgement for their hard work and tireless service. It would be easy to say that what is needed is for all the stakeholders to take a step back so they can see the whole elephant, but this is easier said than done; they are too busy trying to satisfy their own interests. It is also unlikely and unrealistic to assume that the paradigm will change from without, although occasionally hospitals do take dramatic and draconian steps to shake things up. It would be equally naïve to assume that any of the stakeholders is willing to acknowledge the potentially pernicious impact of his or her pursuit of self-interest. No commuter leaving home at 8:30 in the morning is willing to take responsibility for the traffic jam that results when hundreds of thousands of people do the same thing so they can get to work and provide for their families. This is the nature of system problems. Our roles and responsibilities are all defined by a system over which we have little influence and no control. The specific vulnerability of the anesthesia practice is defined by its replaceability. Contrary to popular belief, the anesthesia practice is the most readily replaceable of the five stakeholders listed above. There is no more compelling Continued on page 14
  13. 13. evidence of this fact than the growth of staffing companies such as Sheridan Health Care, NAPA, Sonos, Premier, etc. Many of the nation’s largest anesthesia practices have also become active players in responding to Requests for Proposal (RFPs) and in accepting contract agreements for the provision of services outside their primary catchment area. This explains why customer service has become both a challenge and an opportunity to the typical anesthesia group practice. The challenge is survival, but the opportunity is security. Both are defined by clear evidence of and a compelling commitment to customer service. What makes so many group practices vulnerable is the perception on the part of the O.R. staff and administration that they “don’t get it about customer service.” No service relationship is perfect and it is unrealistic to think that there will not be some disagreements or miscommunciations in the relationship between an anesthesia group and the management of the operating room. The strength of the relationship can best be measured in three areas. The first is the consistency of care provided and the perception of the medical staff. Contrary to popular opinion, superior clinical care is an essential pre-requisite. The second is the way the organization deals with its shortcomings and problems; a perception that a practice is willing to accept its shortcomings and a pro- active approach in addressing them is essential. It is never a good sign when the hospital administrator has a list of “problem” providers. The third and final factor is the management of the practice; practices that have strong leadership and which speak with one voice are always preferred over those that function as loose confederations of independent providers. A lot can be learned from the hospital administrator. Practices that do not have regular interactions with administration are generally more vulnerable than those that do. It is these same three qualities that define the practices with the best and most secure relationships with their hospitals. A commitment to excellence in execution is essential and best practices are continually striving to anticipate clinical needs of the institution. The second quality that creates and engenders confidence is strong internal monitoring and peer review. Best practices not only do various forms of continuous quality improvement but will identify opportunities to have additional staff improve their skills or learn new techniques. There is obviously no one right way to run a hospital or its operating room suite. Because the anesthesia department inevitably has more and better data about what actually happens day to day there is an expectation that anesthesia can be a strong contributor to the ongoing improvement of operating room operations. But by far what distinguishes the strongest relationships is the way administrations interact. If leadership of the anesthesia practice has a good rapport with administration that allows for collaborative problem-solving and strategic planning, then almost nothing else matters. There is no clearer evidence of this that the level of participation in hospital committees. The practices with the tightest relationships to their hospitals are those that are willing to share data and ideas and which make it a point to offer solutions rather than to complain about problems. It is a sad reality that those practices afraid of losing their franchise probably will. Unfortunately, there are many others that don’t even realize just how vulnerable they are. Not a week passes but that some anesthesia group president is surprised to learn that his hospital administrator has decided to send out an RFP. The lesson here is that those groups that fail to take the feedback they are getting from administration seriously are doomed to be victims of their own ignorance. Every organization can be improved and every relationship can be made stronger through communication. The fact is that those organizations that are confident they are providing the best possible care and creating value for the institution and have evidence to prove it will likely enjoy long and profitable relationships. Customer service in the world of anesthesia is all about partnership; the more you commit, the more you benefit; but it is an all or nothing proposition You either get it about customer service or you don’t. the Communiqué Winter 2010 PAge 14 Mr. Locke is respon- sible for the scope and focus of services pro- vided to ABC’s largest clients. He is also re- sponsible for oversight and management of the company’s pain management billing team. He will be a key executive contact for the group should it enter into a contract for services with ABC. He may be reached at Continued from page 13 Customer serviCe in AnesthesiA CAre
  14. 14. the Communiqué Winter 2010 PAge 15 Think back to a recent service experience. This service could have been provided by anyone from an accountant, to a lawyer, to a car mechanic. Ask yourself the following questions about that experience and consider: Did the provider… • Listen carefully to your needs and try to understand what was unique about you? • Communicate in understandable language and explain in advance what they were going to do and why? • Keep you sufficiently informed on progress and make sure they were accessible when you needed them? • Deliver on time and keep their promises? • Offer help or proactive ideas beyond the specifics of the service provided? • Show an interest in you beyond the specific task at-hand and make you feel that you and your business are important to them? If you answered ‘yes’ to most of these questions,chances are you were extremely satisfied with the service you experienced. Grant Thornton LLP is the U.S. member firm of Grant Thornton International Ltd, one of the six global audit, tax and advisory organizations. At Grant Thornton we provide training to help individuals know that it takes providing personalized attention and the highest quality service to build lasting, loyal client relationships. Here are some of the basic components to client service. Client serviCe best prACtiCe: don’t Assume you AlreAdy know the Client’s expeCtAtions— they’re AlwAys ChAnGinG How does one personalize their service approach? It starts with understanding the client’s expectations. As a partner at Grant Thornton, I believe that our personalized service sets us apart because we embrace a common philosophy about what it means to provide exemplary service. Our philosophy is fundamentally client- centric, and our service methodology reflects this: the very first thing we do with each client, at least once a year, is sit down in person to listen and ascertain the client’s expectations, even with clients we serve repeatedly—because expectations are always changing. This conversation helps us hear what’s most important to each client—in their words. So we may distinCtive Client serviCe: five prACtiCes you CAn implement todAy William Kingsley Grant Thornton, LLP, Southfield, MI Continued on page 16
  15. 15. tailor a service approach that fits—not just for the project at hand, but for the relationship overall. Client Service Best Practice: Be A Student Of The Client’s Industry And Business Having a deep knowledge of what makes each industry segment unique is critical to exceeding clients’ expectations. Doing the necessary research and homework up front to have a working knowledge of current trends, hot topics, and challenges not only shows credibility but a genuine interest in the issues important to the people you serve—but don’t stop there. Be sure to also speak directly with your clients and ask them how they would like you to learn more about them and their business. Then, take their advice. They will know better than anyone else and give you an efficient roadmap for making the most of your time and efforts. Remember that clients appreciate it when their advisors can ‘talk shop’ with them, and when conversations aren’t laden with jargon they don’t understand. Using terms that are relatable and within the context of their everyday world is an important part of establishing effective, trusted communication—the backbone of every successful relationship. Client Service Best Practice: Delivering Your Service Is The Prime Time To Add Value, Demonstrate Expertise Having served a broad range of clients over the course of 25 years, I know first-hand that there is no better time to shine than during the day-to-day management of a project or service, when client interactions are frequent: Service providers must demonstrate flexibility in the way they operate, in the ways they communicate, and in the kinds of solutionsthattheyofferinordertoprovide a unique, personalized service experience. When you’re interacting with a client, you have many opportunities to identify ways they might improve or optimize their position. When you think about how you can provide value to a client, especially to a key influencer or decision-maker, it really is in the area of questions. Not just answering the questions they ask, but being able to surface ideas and advise what questions they should be asking— and then helping to answer those. When you can bring something extra to the conversation and help expand the client’s own thought process so they can look even farther ahead to choices that wouldn’t otherwise have been on their radar, you become a trusted advisor to that person and organization. After years of serving a number and variety of clients, you have invaluable, first-hand perspective and knowledge to share that isn’t a commodity. When you proactively share insights from your past or current experiences, it is perceived as adding value and your service is seen as more comprehensive. This is why clients expect more than just technical expertise. They want a provider that focuses on the relationship and strives to help their overall organization improve. Client Service Best Practice: Collaboration Is Key—Throw Away The Cookie-Cutter It’s not often that service is delivered solely by one person. Usually, it takes a team to create a superior service experience. Teamwork means close coordination and collaboration by everyone, from the receptionist to the lead supervisor, to get the job done. Clients expect the left hand to know what the right hand is doing. If they perceive silos in how you operate their confidence declines and their risk of dissatisfaction increases. Teams that collaborate don’t try to fit clients into an answer that they may have already given to somebody else. When teams and clients craft answers together, there is a united focus and commitment that ensures a successful outcome. Client Service Best Practice: Feedback Is A Gift—Use It For Continuous Improvement Every great service organization and professional needs candid feedback to improve and grow.Whether you choose to seek feedback formally through a survey or informally through a one-on-one client conversation, the only way to know how well you are performing is to ask. Take what you learn—both what you do well and what you can do to improve—and take action. Follow up and thank clients for their feedback and communicate what you will do in the future to continuously improve their service experience. Don’t try to fix problems or complaints in the moment or become defensive. Just listen, take notes, and commit to following up. This gesture alone helps strengthen relationships and as you see trends start to emerge in your findings, your ability to hone in on the practices that mean the most important to your clients will serve your business well. Demonstrating these practices repeatedly will not only enhance your clients’ experience but will establish your reputation as a trusted professional—and that is something only the most satisfied clients can do for you and your business. The Communiqué Winter 2010 Page 16 William Kingsley is a tax partner with Grant Thornton, LLP 27777 Franklin Rd. Ste 800, Southfield, MI 48034-2366. He may be reached at bill. Continued from page 15 Distinctive Client Service: Five Practices You Can Implement Today
  16. 16. the Communiqué Winter 2010 PAge 17 As a result of legislation passed under the Bush administration, the $100,000 gross income limit for an individual to convert a traditional individual retirement account (IRA) to a Roth IRA will be lifted in 2010. As a result, regardless of gross household income level, you will be eligible to convert your IRA to a Roth IRA. The only question is “Shall I convert?” Before discussing the reasons “why” or “why not,” let’s review the elementary differences between a traditional IRA and a Roth IRA. Even though both are forms of a retirement account, they have their own distinct characteristics. WithatraditionalIRA,pre-retirement contributions can be tax-deductible. The tax-deductibility is dependent on the individual’s income level and the availability of an employer-sponsored retirement plan for the spouse. The assets within a traditional IRA grow tax deferred until withdrawn at retirement. Each withdrawal is subject to federal income tax. Conversely, contributions to a Roth IRA are made with after-tax money. There is no tax deduction for the contribution. Like a traditional IRA, the assets grow tax deferred until retirement. However,because contributions are made with after-tax money, the withdrawals at retirement are not taxed. This in a sense makes a Roth IRA a tax free retirement asset. The traditional IRA also has required minimum distributions (RMD) beginning at the age of 70½. Once you reach this age, you are required to withdraw a certain percentage of the account value on an annual basis and pay the associated federal income taxes. The Roth IRA on the other hand has no RMD and any withdrawals are tax-free. As noted, this is due to the contributions of a Roth IRA being made with after-tax money. When deciding to convert a traditional IRA to a Roth IRA, you need to consider multiple factors. Many people mistakenly believe, given the opportunity, they should convert. They assume they will be better off having a tax free asset at retirement in the form of a Roth IRA than they will with a taxable asset in the form of a traditional IRA. To make the correct decision, people should consult their tax advisor and be cognizant of the following: Current inCome tAx rAte vs. expeCted inCome tAx rAte At retirement: All other things being equal, the rule of thumb is if you believe your income tax rate at retirement will be less than your current income tax rate, you should not convert. This is because when you convert, you pay income taxes on the total market value of the traditional IRA in the year in which you convert.Consider the following example. Dr. Tom, an anesthesiologist with 25 years of experience, currently has $100,000 in a traditional IRA, and his federal income tax rate is 30%. If he converts to a Roth IRA,he will pay $30,000 in federal income taxes this year due to the trAditionAl irA: shAll i Convert?ScottThompson and Jon Koteski, CFA Oakmont Capital Management, LLC, Oakmont, PA Continued on page 18
  17. 17. The Communiqué Spring 2008 Page 18The Communiqué Winter 2010 Page 18 realization of $100,000 in taxable income. If Dr. Tom leaves the $100,000 in the traditional IRA and doesn’t convert, he will pay taxes when he takes distributions at retirement. If at this time his tax rate is 20%, he will pay 20 cents in federal taxes on every dollar he withdraws. This lower tax profile suggests it may not be beneficial for him to convert today. Conversely, if Dr. Tom is a young resident and just beginning his career, it may make sense for him to convert. This is because there is a good chance his current tax rate may be less than what it is going to be when he retires. But obviously, there is no guarantee. Ability to Pay the Additional Income Tax Associated with the Conversion: If you do not have the excess cash to pay the additional taxes generated from the conversion, it may not be feasible for you to convert. If you use cash from your traditional IRA to pay the additional tax, you may also be subject to a 10% penalty due to it being an ineligible withdrawal. This penalty is in conjunction with any taxes generated. Furthermore, the conversion may put you in a higher tax bracket, especially if you file jointly and both you and your spouse decide to convert. It may make sense to only convert an amount that will permit you to remain in your current income tax bracket or develop a plan in which you do a multi- year conversion with manageable dollar amounts each year. For calendar year 2010 only, if you convert, you can spread the realized taxable income over 2011 and 2012. Estate Planning: For certain estate planning purposes, a Roth IRA may be more attractive relative to a traditional IRA. Assets of both transfer to the beneficiary tax deferred, however, the beneficiaries of a Roth IRA do not have to pay federal income taxes on future withdrawals regardless if they are retired or not. This is not the case with a traditional IRA.As result, a Roth IRA is a simple way of transferring an income tax- free asset to a spouse or heir. Secondarily, the value of the estate is reduced by the income paid due to the conversion. This lowers the overall estate tax liability at death. Stock Market Dynamics: Since the tax liability of the conversion is directly related to the market value of the assets of the traditional IRA, it advantageous to convert when asset values are depressed. This usually occurs during or after a market crisis, similar to one we experienced in 2008 and the first part of 2009. It is especially attractive if you have a significant amount of time until retirement and you can benefit from multiple market cycles through a proper investment strategy. Re-characterization: If you convert today and an exogenous event occurs preventing you from having the means to pay the additional tax liability, the IRS will allow you to “unconvert” or re-characterize your Roth IRA back to a traditional IRA. You can do this up until you file your tax return for the year in which you initially converted. You may also consider re-characterizing if the market value of your Roth IRA assets drops significantly after the conversion. This will allow you to convert in the future at a more attractive market value. “How does the actual conversion process work?”Relatively, it’s quite simple. It’snomoredifficultthanopeningatypical brokerage account and transferring assets into it. Some brokerage firms will even allow you to do the conversion online. If you already have a Roth IRA in place, you may not even need to open a new account. You can refer to IRS Publication 590 for more details on the intricacies. “Shall I convert?” is not an easy question to answer. There are many factors that weigh into the decision. Some have been discussed in this article and others have not. An improper decision or assumption regarding these factors can significantly affect the amount of assets you have at retirement. Do your homework and consult your tax and investment advisors prior to walking down the conversion path. Converting may not always be in your best interests... You may e-mail the authors at and Sources: The Vanguard Group, Inc. Morningstar, Inc. BlackRock, Inc. Continued from page 17 Traditional IRA: Shall I Convert?
  18. 18. the Communiqué Winter 2010 PAge 19 breACh notifiCAtion finAl rule Abby Pendleton, Esq. Jessica L. Gustafson, Esq. The Health Law Partners, P.C., Southfield, MI In compliance with Section 13402 of the Health Information Technology for Economic and Clinical Health (“HITECH”) Act, on August 24, 2009, the Department of Health and Human Services (“HHS”) issued an interim final rule with comment period (“Final Rule”), which requires covered entities and their business associates to provide notification of breaches of unsecured protected health information (“PHI”). The provisions of this Final Rule were effective September 23, 2009. There are several main components of the Final Rule, which must be considered individually. These considerations, which will be addressed each in turn by this article, include the following: • Which entities are governed by the Final Rule? • Has a “breach” occurred? • If yes, did the breach involve “unsecured protected health information”? • If yes, to whom must notification be provided, and what information must be provided? whiCh entities Are Governed by the finAl rule? The breach notification provisions of the HITECH Act and the Final Rule are applicable to “covered entities” and their “business associates,” as these terms are defined by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) Administrative Simplification regulations, codified at 45 C.F.R. § 160.103. Pursuant to these regulations, a covered entity includes a health plan, health care clearinghouse or health care provider that transmits health information in electronic form (an anesthesia practice that submits a health care claim electronically is an example of a covered entity). A business associate is a person or entity that performs functions on behalf of a covered entity that involve the use or disclosure of protected health information. Examples of business associates include billing companies, transcription companies, legal counsel and entities performing management or administrative services for covered entities who require access to protected health information. “Protected health information” (“PHI”) is defined to include, with certain exceptions, individually identifiable health information held or transmitted in any form or medium by HIPAA covered entities and business associates. Anesthesia and pain management practitioners are “covered entities” with access to “protected health information” as defined by the regulations and thus are subject to the HITECH Act and the corresponding provisions of the Final Rule. hAs A “breACh” oCCurred? In cases where a covered entity discovers a disclosure of PHI, the first consideration is to determine whether such a disclosure constitutes a “breach” as defined by the HITECH Act. Section 13400 (1) of the HITECH Act defines “breach” to mean, generally, “the unauthorized acquisition, access, use, or disclosure” of [PHI], which compromises the security or privacy of such information. The Final Rule clarifies that “unauthorized” means “impermissible use.” The Final Rule clarifies that a use or disclosure impermissibly involving more than the minimum necessary PHI may constitute a breach; on the other hand, a use or disclosure resulting from an otherwise permissible use or disclosure involving only the minimum necessary PHI and occurring despite reasonable safeguards would not qualify as a breach. The Final Rule specifies certain exclusions to the term“breach,” including the following: disclosures made to an unauthorized person, where such person would not be reasonably able to retain such information, and further excludes certain unintentional acquisitions, access or uses of information made by employees of a covered entity or business associate, Continued on page 20
  19. 19. the Communiqué Winter 2010 PAge 20 persons acting under the authority of a covered entity or business associate, or individuals otherwise authorized by the covered entity or business associate to access the PHI. In summary, when determining whether a “breach” has occurred, covered entities and business associates must consider the following three matters: (1) whether there has been an impermissible use or disclosure of PHI under the HIPAA Privacy Rule; (2) whether the impermissible use or disclosure compromises the security or privacy of PHI (i.e., is there a risk of financial, reputational or other harm to the individual as a result of the use or disclosure); and (3) whether the incident falls into one of the exclusions of the term “breach” as defined by the Final Rule. did the breACh involve “unseCured proteCted heAlth informAtion”? Section 13402(h) of the HITECH Act contains the general requirements regarding breach notification, and specifies that such requirements relate only to breaches of “unsecured protected health information.” If PHI is not “unsecured,” breaches are not subject to Section 13402(h) of the HITECH Act and the corresponding provisions of the Final Rule. The law defines “unsecured protected health information” as PHI “that is not secured through the use of a technology or methodology specified by theSecretaryinguidance.” Thelawfurther requires that such guidance describe those technologies and methodologies rendering PHI “unusable, unreadable, or indecipherable to unauthorized individuals.” Such guidance originally was published April 27, 2009 at 74 Fed. Reg. 19006, and listed encryption and destruction as the two technologies and methodologies used to render PHI unusable, unreadable or indecipherable to unauthorized individuals. This guidance was clarified with respect to specific encryption processes to employ by way of the Final Rule, beginning at 74 Fed. Reg. 42742. Significantly, the Final Rule does not modify any existing requirements of the HIPAA Security Rule (which is technology neutral), and does not require that covered entities and their business associates encrypt all PHI. The requirements of the HITECH Act and Final Rule relate only to a covered entity’s and/orbusinessassociate’sresponsibilities in the event of a breach of unsecured PHI. • By way of clarification, under the HIPAA Security Rule, encryption is an “addressable,” not a “required,” implementation specification. This means that a covered entity must assess whether encryption would be a reasonableandappropriatesafeguard in the entity’s environment; however, the covered entity may choose not to implement the specification based upon its internal assessment, if it documents the reason and implements an equivalent alternative measure, if such alternative would be reasonable and appropriate. Thus, a covered entity may be in compliance with the HIPAA Security Rule even if it reasonably decides not to encrypt electronic PHI and instead uses an alternative method to safeguard information. In this scenario, in the event that a breach of PHI occurs, even though the covered entity or business associate is in compliance with the HIPAA Security Rule, the covered entity or business associate nonetheless will be required to provide the requisite notification pursuant to the HITECH Act and corresponding provisions of the Final Rule, as the PHI is “unsecured.” • On the other hand, if the covered entity or business associate chooses to encrypt PHI as part of its safeguarding of electronic PHI under the HIPAA Security Rule, and provided that such encryption is in compliance with published guidance in the Final Rule, in the event of a breach, the covered entity or business associate will not be required to provide notification under the HITECH Act and corresponding provisions of the Final Rule, as such information was not “unsecured.” A breACh of unseCured pHI hAs oCCurred. to whom must breACh notifiCAtion be provided,And whAt informAtion must be provided? Notice to Each Individual Following the discovery of a breach of unsecured PHI, a covered entity must notify each individual whose unsecured breACh notifiCAtion finAl rule Continued from page 19
  20. 20. The Communiqué Winter 2010 Page 21 PHI has been (or is reasonably believed by the covered entity to have been) accessed, used or disclosed. Under the Final Rule, a breach is deemed to be discovered either (1) on the first day the entity obtains actual knowledge of the breach; or (2) the day on which the breach would have been known had the covered entity exercised reasonable diligence. Per the Final Rule, the notification to each individual must be made “without unreasonable delay and in no case later than 60 calendar days after discovery of a breach.” Such notice must be written in plain language, and must be made either (1) via first class mail to the individual (or to his or her next of kin or personal representative, if such individual is deceased) at the individual’s last known address, or (2) via email, if the individual agreed to receive such communications via email. The written notice must include the following elements: • A description of what happened with respect to the breach, including the date the entity discovered the occurrence of the breach; • A description of the types of unsecured PHI that were involved in the breach; • A description of those steps individuals should take to protect themselves from any potential harm resulting from the breach; • A description of the covered entity’s actions to investigate the breach, to lessen the harm to the individuals affected by the breach, and to protect against further breaches; and • The contact information for individuals to obtain additional information, which should include a toll-free telephone number, an email address, a website or a postal address. In the alternative, codified at 45 C.F.R. § 164.404 (d) (2), the Final Rule also sets forth requirements for substitute notice, permissible in cases where a covered entity has insufficient or out-of- date contact information for individuals that are the subject of a breach of unsecured PHI. Notification to the Media In the event a breach of unsecured PHI involves more than 500 individuals, the covered entity also must notify prominent media outlets of the breach. Such media notification must include all elements included in the individual notification, and must be made without unreasonable delay, but in no case later than 60 calendar days after the discovery of the breach. Notification to HHS In all cases in which a covered entity discovers a breach of unsecured PHI, the covered entity must notify HHS. If the breach involves 500 or more individuals, the notification to HHS must be made at the same time notification to each individual is made. If the breach involves fewer than 500 individuals, the covered entity will maintain documentation of the breach and provide notification to HHS no later than 60 days following the end of the calendar year. Business Associates The Final Rule also requires that business associates notify the covered entity of any breach of unsecured PHI that occurs. Such notification must be made without unreasonable delay and in no case later than 60 calendar days after discovery of the breach. Conclusion The Final Rule requires that anesthesia and pain practices adopt and implement policies and procedures related to the breach notification provisions of the HITECH Act and Final Rule. The Final Rule also requires that these entities train their workforce members regarding these breach notification requirements. As a practical matter, because the provisions of the HITECH Act and Final Rule are rather detailed, covered entities and business associates should train their employees to inform the HIPAA Privacy or Security Officer of any potential breach, so that the entity’s management can render a decision as to what notification, if any, must be made. This is not an easy task and will likely require investigation and coordination with legal advisors. Abby Pendleton and Jessica L. Gustafson are partners with the health care law firm of The Health Law Partners, P.C. in Southfield, Michigan. The firm represents hospitals, physicians, and other health care providers and suppliers with respect to their health care legal needs. Pendleton and Gustafson specialize in a number of areas, including but not limited to: Recovery Audit Contractor (RAC), Medicare, Medicaid and other payor audit appeals, healthcare regulatory matters, compliance matters, reimbursement and contracting matters, transactional and corporate matters, and licensing, staff privilege and payor de-participation matters. They can be reached at and Abby Pendleton Jessica L. Gustafson
  21. 21. the Communiqué Winter 2010 PAge 22 Recent legislative initiatives to restrict (or eliminate) the Stark law’s In-Office Ancillary Services Exception (the “IOASE”) are, by no means, a new phenomenon. Rather, over the last few years, the Centers for Medicare and Medicaid Services (“CMS”) has introduced several significant proposals targeting the provision of certain ancillary services in the physician office setting, through proposed changes to the Stark regulations and other Medicare reimbursement and performance regulations. Despite these proposals, however, the IOASE remains intact and the prospect of a near-term wholesale elimination of the IOASE appears remote. Although for many pain management physicians the Stark ban on physician self-referral is not triggered (if the only ancillary services provided are certain invasive radiology procedures such as fluoroscopy), for many other pain management physicians who provide physical therapy (“PT”) or other diagnostic testing in their offices, the Stark law remains a relevant consideration and they must stay attentive to potential changes to Stark’s IOASE. This article provides a brief overview of the IOASE, as it relates to pain management practices and discusses the current status of the IOASE, which permits (and, we expect, will continue to permit) appropriately structured in- office PT and other ancillary service arrangements in the physician (including pain management practice) setting. the ioAse- A brief history The federal Stark law prohibits physicians from referring Medicare patients to entities that provide “designated health services” (DHS) (including, for example, PT and diagnostic imaging services) if the physician (or his/her immediate family member) has a financial relationship with that entity, unless a Stark exception applies. The IOASE is the statutory vehicle that permits physicians and group practices to furnish DHS in the office, with the goal of balancing beneficiary convenience, efficiency of services, quality and continuity of care, on one hand, against the prevention of abusive sham arrangements that do not have a bona fide nexus to the physician’s core medical practice, on the other hand. A substantial majority of office-based ancillary service arrangements rely upon the IOASE to enable referring physicians to provide these services within their practices. Specifically, this exception the stArk lAw’s in-offiCe AnCillAry serviCes exCeption: in-offiCe AnCillAry ArrAnGements remAin viAble for pAin mAnAGement prACtiCes Adrienne Dresevic, Esq. Carey F. Kalmowitz, Esq. The Health Law Partners, PC, Southfield, MI
  22. 22. the Communiqué Winter 2010 PAge 23 protects in-office ancillary arrangements if the services are provided or supervised by the referring physician or his/ her group, billed by the performing physician/group (or the group’s wholly- owned subsidiary), and provided either in the same building as the physician’s/ group’s office or a centralized building cite operated exclusively by the group practice. Notably, the IOASE was contained in the original Stark statute adopted by Congress in order to preserve the long-standing practice of physicians integrating within their practices those ancillary services that complement the professional physician services they furnish. Cms’ eArlier proposAls tArGetinG the ioAse In recent years, CMS has introduced various legislative proposals which, in one form or another, effectively attempted to restrict (or eliminate) the IOASE. Most of these original proposals, however, were either never finalized, or implemented in manner that did not substantially affect many common in- office ancillary service arrangements involving true in-office integration. The 2008 Medicare Proposed Physician Fee Schedule, for example, contained commentary by CMS expressing concern that the IOASE was being inappropriately used for services that were not closely connected to the physician’s core medical practice. At that time, CMS solicited comments on potentialchangestotheIOASE,including whether certain DHS should be excluded from the exception, whether the location requirements of the exception should be tightened, and whether the exception should be available for specialized services involving equipment owned by non-specialists. CMS, however, to date has not introduced a formal proposal to materiallyrestrictthescopeof theIOASE. Any revisions to the IOASE will require a future notice of proposed rulemaking withprovisionforpubliccomment. CMS has noted that any future rulemaking will present a coordinated, comprehensive approach to accomplishing the goals of minimizing the threat of program abuse while retaining sufficient flexibility to enable arrangements that satisfy the requirements and intent of Stark. In a related matter, recently CMS took a relatively flexible position when it finalized the Medicare Anti- Markup Rule (the “AMR”) (which applies to many common diagnostic testing arrangements). Although the original AMR proposals would have placed restrictive payment limitations on a significant number of such arrangements, in the form the AMR initially was adopted, if a physician group is willing to exercise certain operational flexibility, substantially all of its diagnostic testing arrangements that are structured to comply with the IOASE likewise can be structured in a manner that does not implicate the AMR’s restrictive payment limitations. Further, under the AMR, CMS permits the use of shared space diagnostic testing arrangements between physicians who furnish physician services, as well as the DHS that are the subject of the shared arrangement, in the “same building”. CMS did caution that it may issue proposed changes to the IOASE in the future, but expressly noted that it had been asked to consider, and rejected, a complete elimination of the IOASE. Recently, CMS has also promulgated some significant federal Stark regulatory changes that impact certain ancillary service arrangements, such as eliminating the use of “per-click” fee and percentage-based payments in space and or equipment leases when the payments reflect serviced provided to patients referred between the parties. Notably, however, these changes do not prohibit the overwhelming number of common Continued on page 24
  23. 23. The Communiqué Winter 2010 Page 24 in-office ancillary service arrangements that are structured to comply with the IOASE. In yet another attempt to target certain IOASE arrangements, in 2008, CMS introduced a proposal that would have required any physician practice furnishing in-office diagnostic testing services (e.g., ultrasound, x-ray, CT, MRI, etc) to enroll as an independent diagnostic testing facility (“IDTF”), with the result that these practices’ diagnostic testing services would be subject to the substantial majority of IDTF performance standards. If adopted, this proposal would have eliminated physician practices’ ability to share diagnostic testing equipment and facilities, even if located in the “same building” as defined under Stark. As a practical matter, this proposal would have also resulted in a significant decline in the number of pain management practices that furnish diagnostic testing services to their patients. Ultimately CMS declined to implement this IDTF proposal. The Current State of the IOASE In recent years, through a series of proposals, CMS has heightened its focus on certain in-office ancillary service arrangements, including arrangements structuredincompliancewiththeIOASE. However, despite these proposals, the IOASE remains intact as the statutory vehicle that permits pain management specialists to furnish both diagnostic testing services and PT services in their offices. Pain management specialists furnishing such in-office ancillary services should remain attentive to potential future regulatory changes that might further restrict the scope of the IOASE. As a result, parties to such arrangements should consider inclusion of well-designed strategies to unwind or restructure these transactions if regulatory changes preclude physicians’ participation in such arrangements. At this point, however, it appears that a near-term elimination of the IOASE remains a remote prospect. The Stark Law’s In-Office Ancillary Services Exception: In-Office Ancillary Arrangements Remain Viable for Pain Management Practices Continued from page 23 Adrienne Dresevic, Esq. is a found- ing member of The Health Law Partners, P.C. Ms. Dresevic practices in all areas of healthcare law and devotes a substantial portion of her practice to providing clients with counsel and analysis regarding Stark and fraud and abuse. Ms. Dresevic can be reached at Carey F. Kalmowitz, Esq. is a founding member of The Health Law Partners, P.C. Mr. Kalmowitz practices in all areas of healthcare law, with specific concentration on the corporate and financial aspects of healthcare, including structuring transac- tions among physician group practices and other healthcare providers, development of diagnostic imaging and other ancil- lary services joint ventures, physician practice, IDTF and home health provider acquisitions, certificate of need, compliance investigations, and corporate fraud and abuse/Stark analyses. Mr. Kalmowitz can be reached at Adrienne Dresevic Carey F. Kalmowitz
  24. 24. the Communiqué Winter 2010 PAge 25 On December 1, 2009, the United States Court of Appeals for the Sixth Circuit affirmed the conviction of Ohio anesthesiologist Dr. Jorge A. Martinez who was charged with illegally distributing controlled substances, mail fraud, wire fraud, and healthcare fraud, including two counts that resulted in the death of patients. In 2002, the FBI began investigating Dr.Martinez’s pain management clinic in Parma,OHinresponsetoreimbursement and billing patterns placing him above his peers for certain procedures. At trial, the government alleged that from 1998 until 2004, Dr. Martinez engaged in fraud and endangered patients by omitting physical examinations of the patients, ignoring “red flags” of patient addiction to pain medication, providing more injections than were medically necessary or advisable and providing at- risk patients with treatments that would likely lead to increased dependence upon him for additional pain medication. The government was able to demonstrate that Dr. Martinez administered far more injections than his peers (e.g., each of Dr. Martinez’s patients averaged 64 nerve block injections per year whereas the state average for pain patients in Ohio was 2.5 nerve block injections per year). Moreover, Dr. Martinez saw more patients per day than other physician in Ohio, sometimes exceeding 100 patients during an 8.5 hour timeframe. Witnesses testified that he frequently spent only 2 to 5 minutes with patients during their scheduled appointments and performed little or no physical examination during these brief visits. The government also demonstrated that two patient deaths were reasonably foreseeable consequences of Dr. Martinez’s course of treatment which fell far below the applicable standards of care. Much of the government’s case focused on Dr. Martinez’s failure to comply with the requirements for billing the highly-reimbursed nerve blocks he allegedly performed. While the applicable standards of care require careful, precise placement of the injection needle, Dr. Martinez was seen entering the room, quickly and repeatedly injecting patients, and exiting the room—all within a few minutes. One of the main issues on appeal concerned the government’s use of video evidence of a non-witness physician performing a nerve block injection in the “proper” manner— creating a direct visual contrast between what was labeled as the proper way to perform the injection and the manner in which Dr. Martinez performed the injection. The Appeals Court found that while the video evidence did constitute impermissible hearsay, its admission was harmless in light of the overwhelming evidence that Dr. Martinez was not performing medically necessary procedures and that the procedures he was performing were not the same as the ones for which he billed. In addition to upholding Dr. Martinez’s conviction, the Appeals Court also upheld his sentence for life imprisonment and over $14 million in restitution. The full text of the case can be found at: http://www. v.%20Martinez.pdf. Robert S. Iwrey is a founding partner of The Health Law Partners, P.C. in Southfield, Michigan, where he focuses his practice on contracts, litigation, dispute resolution, licensure, staff privileges, Medicare, Medicaid and Blue Cross/Blue Shield audits and appeals, defense of health care fraud matters, compliance and other healthcare related issues. He may be contacted at (248) 996- 8510 or 6th CirCuit federAl Court of AppeAls Affirms ConviCtion of pAin mAnAGement physiCiAn for overutilizAtion & billinG frAud Robert S. Iwrey, Esq. The Health Law Partners, P.C., Southfield, MI
  25. 25. The Communiqué Winter 2010 Page 26 Introduction Susan Petitt Manager, Operations and Client Support, ABC Customer service is a reflection on an organi- zation’s values and be- haviors, as well as on each individual who works there. Anesthesia Business Con- sultants (ABC) embraces the practice and culture of providing high quality service to its clients. Effective communications and interactions are critical to continue to foster the successful relationships we have with the more than 8,000 anesthesia and pain providers we do business with. Our Western Region staff offer the following thoughts that can apply to us all: • Effective listening to our partners’ needs to ensure we address real issues, while also working proactively with our part- ners to maintain strong relationships and successful results. • Managing expectations - Understanding our partners’ expectations of us, while also clearly communicating our expecta- tions of our partners. • Effectively using technology, while inves- tigating powerful new tools and resources for greater efficiency internally and in our partners’ organizations. • Operating within the philosophy of‘truth in customer service’. We believe in work- ing smartly and honestly to instill trust and alliance with our partners. Effective Listening Annie Jaouak Supervisor, Customer Service, ABC Do you really listen? Al- though we may inter- change one for the other in our daily communication, there are cru- cial differences between listening and hear- ing. Hearing requires two ears whereas lis- tening requires both ears and mind. Listen- ing is work; brain work, and it requires both sustained and honest effort. “Frustrated”, “devalued” and “disrespected” are all terms used to express feelings when we believe that we have been heard but not listened to. When we listen we hear with thoughtful intention to act upon what we have heard. Additionally, when we actively listen; we pay close attention to the speaker’s verbal and non verbal messages. It is this kind of listening that results in successful and grow- ing relationships. Let’s look at some of the most com- mon causes of non-effective listening. • It has been said that we have two ears and one mouth and should use them in that ratio. A common impediment to ef- fective listening is that many of us have conditioned ourselves to fill in the blanks, surge to the end of a conversation and conclude a speaker’s thoughts prema- turely. Doing this shuts down the speaker and closes off communication. • Another common impediment is the non-verbal messages we send. A funda- mental axiom of communication is also that we as human beings cannot com- municate. The impossibility of not com- municating means that we send messages even by our absence of intent. Failing to show up at an event or leaving the room suggests meanings to others. Because communication is unavoidable, it is es- sential that we are continually consider- ing the unintentional messages we send. Facial expression, posture, gesture, cloth- ing, and a host of other behaviors offer cues about our attitudes. Those who have acquired the talent of effective listening have advanced a long way toward more successful relationships. Expectations KD Lowe Senior Vice President, ABC Having worked in hos- pitals for 19 years and with physicians for 12 years, and having raised six children with my wife of 36 years, I have come to appreci- ate both the danger and value of expecta- tions. Years ago as I raised my children, I came to the realization that the majority of times I felt anger in my life, it was caused by unmet expectations. I also realized much of the time those expectations were vague and undefined, or at least not communicated clearly to the other party. We all have expectations of others. Let me suggest two principles of success tied to expectations that we should all come to know. • Expectations require clarity of defini- tion. In all our relationships, it is gener- ally understood that meeting each other’s expectationsisimportanttoassureagood relationship. Can we accomplish this if we don’t understand clearly what those expectations are? For example, patients expect high quality, affordable healthcare. Do we in healthcare understand how each of our patients might define that? We may think we do, but experience has taught me that when I assume that I do, the risk of being wrong goes way up. Take the initiative and clearly define your ex- pectations of others in your own mind, and in advance, so you are ready when appropriate to clarify them to others. • Expectations require communication. It is also important that at some point in a relationship, that we take a moment to communicate with and educated others on how we define our expectations. Ex- pectations go both ways, and it is equally important that both parties understand Perspectives on Client Service From ABC Senior Staff