How doctors should think? Who are physicians? How do they boost their practice? How they should think about Revenue Streams.

Disclaimer
Copyright © Year – All Rights Reserved
Learn How You Can
Change Your Practice
for the Better!
How Doctors Should Think

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All ideas, views and thoughts expressed in this book are the author’s own. References have
been provided wherever possible. This eBook is not meant for promotional or advertising
purposes.
Examples of people and other organizations are mentioned as case studies only. Any
comments which could be deemed as negative or as criticism are completely unintentional
on the author’s part.
All information contained here is meant to be taken as a guideline. It is understood that the
reader claims responsibility for their own actions and interpretations of the advice
provided herein.
The author does not claim nor was any guarantee made regarding success through this
book. This eBook is not meant to be a substitute for professional advice. Therefore, they
cannot be held responsible should any losses, risks, liability or damages that might be
linked, directly or indirectly, with the information contained within this book should occur.
Contents
Disclaimer.........................................................................................................................................................................1
Chapter 1 –Introduction............................................................................................................................................4
Chapter 2 - The Core Question – What is a Physician? ...............................................................................7
Don’t be a Caterpillar.............................................................................................................................................7

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What is a Physician?...............................................................................................................................................9
Chapter 3 –Thinking for a Change.....................................................................................................................12
Chapter 4 –When Going in the Wrong Direction, Don’t Speed Up.....................................................15
Chapter 5 –Dot Thinking........................................................................................................................................18
Chapter 6 – Two SD to the Right.........................................................................................................................21
Chapter 7 – Be More like George........................................................................................................................24
Chapter 8 – Secrets to Boost Your Practice...................................................................................................27
Get Computerized.................................................................................................................................................27
Take Control of Your Office..............................................................................................................................28
Create a Niche.........................................................................................................................................................29
Offer One-Stop Shopping...................................................................................................................................31
Hire As Few Employees as Possible.............................................................................................................31
Pay As Little Rent As Possible.........................................................................................................................35
Chapter 9 – Doctors Have to Know Their Business...................................................................................37
Chapter 10 – Why Did You Sign Contracts with Insurance Companies...........................................42
Chapter 11 – In Network, Out of Network.....................................................................................................49
Review........................................................................................................................................................................54
Chapter 12 – Cash Only and Concierge Practice.........................................................................................54
Concierge Practices..............................................................................................................................................57
Chapter 13 – The Value of Intellectual Distribution.................................................................................59
Chapter 14 – How Doctors Should Think About Revenue Streams...................................................62
Time Testing and Treatment...........................................................................................................................62
Testing........................................................................................................................................................................66
Treatment.................................................................................................................................................................70

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Chapter 1 –Introduction
One thing I have learned by reading a lot of personal development books is that if you see
someone who is doing something you want to do, find out how they did it and follow the
same steps. Success has a methodology to it. There is a science to living the life that you
want to live. The most important first step is to decide that you want something different.
This is a lesson that I learned when I was disenchanted with the life I was living. I was a
doctor with a large practice, 6 doctors, working hard but barely able to make ends meet in
my practice and at home. One of the drawbacks associated with being the owner of a

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business and an employer is that when money is short, all employees must be paid but the
owners don’t have to be paid. After missing several paychecks, a decision was made. My
wife said something has to change.
Close to that time, I was introduced to the Anthony Robbins’ series of tapes entitled
“Personal Power.” What I learned from listening to over 20 hours of tapes is that for
anything to change, the most important first step is deciding to change. The power any
person has is the ability to decide and act on that decision. But first you have to make a
committed decision. The power to decide is everyone’s personal power.
Most doctors today feel like they have no power. I hear doctors all the time telling me how
they are controlled by the pharmaceutical industry, forcing them to use their drugs by
advertising on television and how the insurance company has control over the number of
patients they have to see and what tests and treatments the doctor can offer the patient.
Doctors feel trapped with no way out.
Why? Because they look around, and all their colleagues are doing the same thing and
voicing the same complaints. Doctors are drawn to other doctors who are suffering because
misery loves company.
Let me share what I have learned. The only way you lose power is if you willfully give your
power away. Doctors gave their power to insurance companies. Managed care
representatives came into offices and told doctors to sign a contract or they would no
longer be able to see patients with that particular insurance. Doctors buckled under the
fear they will have an empty waiting room.
Let’s look at this in a different way. The insurance company is selling to the consumer
access to health care. How can they deliver access to health care unless they have
healthcare providers in the network? What would happen if no doctor signed the contract
to discount their fees and allow the insurance company to control medical decision-
making?
The insurance company would have nothing of value to sell to the consumer. In the
previously described scenario, who has the power: the insurance company or the doctor?

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The insurance company has no one that can provide healthcare. The insurance company
only employs business people. If the doctor did not willfully sign the contract, which gives
away the doctor’s power, the insurance company would fold.
Because doctors gave this power away, physicians are going bankrupt, closing their
practices and selling their practice to the hospital. Why? Doctors relinquished their power.
Doctors complain the pharmaceutical industry has all the power. Doctors comment that
they are helpless because of the pharmaceutical industry lobbyist in Washington influence
Congress and leave the doctor no choice but to prescribe medication. This is another
example of willful surrender of power. The pharmaceutical representative, Congress, the
president or the patient cannot force you to write and sign a prescription. Prescription
rights have only been given to doctors in most states. If doctors stopped writing
prescriptions, the pharmaceutical industry would fold in days.
Every dollar in medicine is generated from a doctor or a doctor’s order. Doctors order all of
the tests and treatments that the patient receives. Each company that provides the test and
treatments are businesses that attempt to generate a profit. Without a doctors order none
of those companies could generate any income.
Doctors unknowingly have ALL the power in medicine. Doctors need to realize this fact.
Doctors also need to stop relinquishing their power to others. When I realized this, I
stopped signing contracts given to me by insurance companies. I terminated all existing
contracts with insurance companies. I don’t allow any pharmaceutical representatives in
my office. I use few pharmaceutical drugs and I am not forced to see 30 patients a day to
make ends meet because I discounted my rates.
I am thankful to Tony Robbins for opening my eyes to the power I possessed.
This book is a personal and professional discovery of how to take back control of all aspects
of your professional and personal life as a physician. This journey started me, my wife and
my family when we stopped thinking like most doctors and started thinking how a doctor
should think.

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Chapter 2 - The Core Question – What is a Physician?
First, let’s go over a story.
Don’t be a Caterpillar
One of the books that taught me a different way of
thinking is “What The Bible Says About Healthy
Living” by Rex Russell, M.D. This book told a story
that has become what I am known for after
physicians hear me speak. I have used this story to
illustrate how dangerous it is to follow blindly behind
leaders.
The story goes like this. There is a type of caterpillar called a processionary caterpillar. The
processionary caterpillar will pick a leader and the other caterpillars will proceed to follow
the lead caterpillar. Instinctively, the lead caterpillar will lead the caterpillars to food and
shelter to assure the survival of all the caterpillars. This is the outcome when the lead
caterpillar follows caterpillar instincts.
However, if the caterpillar is influenced, manipulated,
pressured and repositioned, for example, a human
Processionary caterpillar line

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intervenes and forces the caterpillars into a circle formation, the caterpillars will die.
Why? Because caterpillars think the other caterpillar in front of them is following the lead
caterpillar. They all assume the leader is going to lead them to food and shelter. They
assume the lead caterpillar is following caterpillar instincts and not just doing what they
see the caterpillar in front of them doing. They don’t know that the lead caterpillar has
been forced to form a circle that leads to nowhere. This is what happens when one does
not follow their instincts and succumbs to outside forces. They go around in circles and
eventually die.
In medicine, the natural instinct leaders should follow is science and physiology. As
physicians, we all took an oath to first do no harm. Hippocrates also said let your food be
your medicine and your medicine be your food. Our leaders in medicine have let outside
influences force them into disregarding these instincts. Our outcome is the same as the
caterpillars: healthcare is going around in circles and credibility is dying.
Because medicine often disregards science and physiology, we recommend treatments that
have no scientific basis and disrupt physiology. This is why we continue to discover the
consequences of our recommendations years later.
Also, because we allow the pharmaceutical industry, insurance companies, and the
government to impose their instincts on the medical community, science and physiology
are ignored and the bottom-line rules all.
Because we disregard “First do no harm,” we allow drug companies to air commercials
about drugs that are forced to tell you about the 20 side effects and possible death the drug
can cause. The juxtaposition of dangerous side effects being read and the image on the
screen depicting happy people that have supposedly taken the medicine make us numb to
the dangers of the medication.
Because we disregard “let food be your medicine”, we genetically modify our food, which
disrupts its nutritional qualities. Now, the body recognizes these foods as foreign to the
body and causes inflammation. Inflammation has been linked to almost every chronic
condition patients’ experience.

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Finally, in business, we follow the crowd. Doctors sign contracts that benefit the insurance
company and the insurance company business model. That same contract is awful for the
doctors’ business. The contract forces the doctor to spend less time with the patients, work
more and get paid less.
Why would a doctor do that? Because that is what the other doctors are doing. This
business model ignores every natural business instinct. But, because doctors don’t learn to
think like a business person, they are gullible to the astute business practices of the
pharmaceutical industry and the insurance industry.
What is a Physician?
The reason why I ask this question is that after years of practicing medicine I did not feel
like I was doing what I thought I would be doing when I dreamed of being a doctor when I
was 12 years old. I decided to look up the definition of a physician and how I could restore
the dream that I had as a 12-year old.
I looked up the definition of restore.
 –verb (used with object), -stored, -stor·ing.
 1. to bring back into existence, use, or the like; reestablish: to restore order.
Restore order.
The order in medicine needs to be restored. I spent several years learning physiology and
biochemistry. This is the basic science of how the body works. Medicine does not follow
science and physiology. Order means that someone is leading and others follow in a specific
order.
As I characterized in my caterpillar story, the order has been disrupted. Science and
physiology has been removed from the leadership position. Medicine is led more by what
the insurance company will reimburse. Medicine is being led by the medication that is the
most profitable to the pharmaceutical company.

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 2. to bring back to a former, original, or normal condition, as a building, statue, or
painting. Patients want to be restored to their original normal condition. I ask
patients when they last felt normal or good. Patients can remember feeling good.
They can tell you the event that led to them not feeling good any more. Patients long
to be restored to normal again. Feeling normal does not mean relieving symptoms
24 hours at a time. Patients want to feel normal without medication like they
remember.
 3. to bring back to a state of health, soundness, or vigor. Patients and doctors want
to be healthy, have a sound body and vigorous health. There is a difference between
not being sick and being healthy. Doctors have been trained to identify sickness not
restoring health. A patient may not be sick but not back to the normal health they
remember.

This is often the ‘disconnect’ between doctor and patient. The patient complains that
they don’t feel normal. Their vigorous health is a distant memory. The doctor
proceeds to prove they are not sick. The ‘disconnect’ is that they are both right. The
patient is not “sick”, and the patient does not have normal vigorous health either.
 4. to put back to a former place, or to a former position, rank, etc.: to restore the king
to his throne. I remember when I was 12 years old I had surgery. The doctor who
took care of me seemed like a god. Doctors were held in such high regard at the

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time. That is when I decided that I wanted to be a doctor. I thought that was the
highest goal I could ever reach. I don’t think, no, I know, that is not the case
anymore.
Managed care came in to medicine and gave the message to patients that doctors are
worth no more than $10 to $20 co-pay. Doctors have lost their position in society
and their authority when it comes to healthcare. Patients will take the advice of a
GNC store clerk over the advice of a doctor. Patients are now more concerned about
maintaining health than waiting for disease and eradicating the disease.
The other definition I looked up was “physician.”
The definition includes, “a person who is skilled in the art of HEALING.” I equate healing to
what happens when someone breaks a bone. When someone breaks a bone, an x-ray is
done to see what is broken, out of place, out of line.
The bone is put back in place. The bone is kept in place for a certain period of time. When
the bone is “healed”, the cast is removed and no further treatment is needed. There is no
need for the patient to take medicine for the rest of their life to maintain or manage the
broken bone once the bone has healed.
There are few things doctors know how to heal. As an ob/gyn, I healed few conditions. I
managed bleeding with birth control pills. I removed organs that relieved symptoms. I gave
antidepressants to manage mood swings but I did not know how to heal or correct
hormonal imbalances. I did not know how to heal the effects of stress. I did not know how
to help the gut heal. Because after you allow the body to heal itself by putting what is
broken back in line, continued therapy is no longer needed.
When I speak to physicians, I challenge them to be careful referring to themselves as a
physician if they don’t know how to heal anything.Only if you know how to heal something
can you be called a physician. It is in the definition of the term, after all. Reclaiming
personal power is not going to cut it, on its own. You have to be a true physician.

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And this is the way you and all other doctors should think. You need to know how to heal
the human body, at least the part of the body you specialize in treating. Combine this with
reclaiming your independence from the business in the healthcare sector and you become a
physician in the true sense of the word.
Chapter 3 –Thinking for a Change
One of the most life changing books I have ever read is the book “Thinking for a Change” by
John Maxwell. The book has been renamed “How Successful People Think”. The premise of
this book is that for anything in your life to change, the way you think must change first.

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If you are not thinking then it is imperative that you start thinking. The one quote that was
particularly impactful to me was the following:
“The problem with popular thinking is that it doesn’t require you to think at all. It is easier
to do what other people do and hope that they thought it out.”
I think most physicians have been forced not to think. This has led to physicians being
much less effective in the healthcare arena. In the book “How Doctors Think” by Jerome
Groopman, M.D., he points out how doctors have been programmed not to think. Doctors
have been forced to except treatment algorithms that have been thought out by some
committee. They have treatment guidelines enforced on them by insurance companies.
Moreover, the state medical board wants doctors in a particular area to practice under the
same guidelines. The standard of care states doctors should do what most reasonable
physicians in their area are doing. This epitomizes the quote about popular thinking.
Legally, doctors should do what other doctors in their area are doing and hope that they
thought it out.
Not only have doctors been forced not to think about how they practice medicine, they
have also been forced to think like everyone else about the business model they follow in
their practice. I saw who I thought were successful physicians have overcrowded waiting
rooms.
Patients would wait for 2 and 3 hours to spend 15 minutes with the doctor. The physician
would spend late hours at the office and the hospital. It often led to them neglecting their
families, which often led to the break-up of the family. Most doctors strive to duplicate this
model because that is what popular thinking projects as a successful doctor.
Remember, popular thinking does not require you to think at all. This is a prime example.
If you think about it, why would anyone call this success, especially now, with managed
care forcing doctors to accept less for doing what I saw doctors doing in the 1980s and
1990s.
Here are a few questions you should ponder on:

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Chapter 4 –When Going in the Wrong Direction, Don’t Speed
Up
The only way the caterpillar can survive and live a long healthy life is to follow the natural
instincts of the caterpillar. (See Chapter 2, “Don’t be a Caterpillar”). The caterpillar
eventually dies because of poor leadership, in fact blind leadership. The caterpillar trusts
the caterpillar in front, believing that he knows where to go. Don’t be a caterpillar. Get out
of line.
The only way you can discover whether you are in a caterpillar line is to actually leave the
line and take a look at the activity of the line. In other words, as long as you are in the
caterpillar line, you are unaware that you are actually not going anywhere. There must be a
time when you must make a conscious decision to slow down, stop what you are doing and
examine yourself, your actions and the direction you are heading in.
If you are traveling down the wrong highway or going in circles, you have to take the time
to look around and notice that you are seeing the same landmarks. If you blindly look
straight ahead, you will go further in the wrong direction and it will take you longer to
reach your desired destination.
If you look around and see that you are not headed in the right direction, you need to pull
off to the side of the road, stop and re-chart your course and then move towards the
desired goal. Nowadays, even the GPS in the car notices the wrong landmarks immediately
and recalculates.

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The problem most doctors have is that they, like the caterpillar, do not realize that the lead
physicians have been influenced by outside influences and are following instincts other
than their own. The instinct of the insurance company and the pharmaceutical industry is
to increase the value of the stock for the shareholders who own the company.
This is the fiduciary duty of any publically traded company. These companies are doing
what they are legally bound to do. These companies achieve their goal at the expense of the
doctors. The insurance company increases the value of its stock by collecting more
premiums and paying out less in reimbursements to doctors and hospitals. Instinctively,
these companies try to sell their insurance to more and more people for the highest price
the market will bear.
Secondly, the insurance company goes to the doctor and intimidates them into signing a
contract that discounts the physician’s fee to the lowest possible price. In order to make
this work, the insurance company must accommodate all of the people they sold insurance
to so they tell the doctor to spend less time with each patient.
Great, the insurance company’s instincts have been followed and met. This is awful for the
doctor and the patient. The doctor is working harder for less money. The patient is
spending less time with the doctor. The doctor doesn’t really know the patient, the patient
doesn’t really know the doctor, and so the cycle continues.
Where there is no relationship, there is no trust. When the goal of the doctor is to see as
many patients as quickly as possible, mistakes will happen and snap diagnoses will be the
order of the day.
Now, this is where the pharmaceutical company gets into the act. The one unique thing a
licensed physician can do is write a prescription. The pharmaceutical company needs the
physician to make money and therefore increase the value of their stock. (Instinct) In the
past, the pharmaceutical representative would wine and dine the doctor, take them on
expensive trips and label them as an educational expense. The laws have changed and this
is no longer possible.

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How did the pharmaceutical company solve this problem? They went for direct to
consumer advertising. The pharmaceutical companies create conditions that are based on
symptoms and have no definitive diagnostic test, for instance, depression, chronic fatigue,
attention deficit, irritable bowel, and erectile dysfunction. There is no way the doctor can
prove that the patient doesn’t have these conditions.
Next, create a commercial that glorifies the particular drug. At the end of the commercial
you usually hear, ask your doctor “is this drug right for me?” The patient sees this
commercial 10 times. They are convinced that they have one of these conditions. They have
seen the imagery in the commercial that shows how happy people are when they are taking
the advertised drug.
The patient asks the doctor for the drug. The doctor has no way of testing whether the
patient has the condition or not. He has only ten minutes to see the patient. The quickest
and easiest way to stay on schedule is to write the prescription and move on to the next
patient. Again, the pharmaceutical company wins, drug sold, profit made, and stockholders
happy. Again, doctor and patient lose.
The doctor has opened himself up to the possibility of missing the true diagnosis, or maybe
the doctor gave a patient a drug they did not need. Now there is the possibility that the
patient will have one of the many side effects the commercial mentions while the imagery
of the happy people is shown in the commercial.
STOP!!!!!!
The doctor is the only one in this equation who took the Hippocratic Oath: “First do no
harm.” The doctor’s responsibility is to instinctively not harm the patient. The insurance
company has not sworn to this oath. The pharmaceutical company has not sworn to this
oath. They have no obligation to the patient. Only the doctor does.
If seeing a patient for only ten minutes harms the patient, then stop. If blindly writing
prescriptions may harm the patients, stop. If signing a contract with an insurance company
could possibly lead to doing harm to a patient, then don’t sign the contract.

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It is that simple. If you follow the correct instincts, order will be restored. The insurance
company does not have a network of doctors to offer to their customers if no doctors sign
the contract. The pharmaceutical company representatives cannot write prescriptions.
Only the doctors can do that.
If the doctor refuses to write prescriptions that can harm the patient, the pharmaceutical
company loses, and the doctor and the patient win. Now, the doctor is being led by the
correct instincts. The insurance company is no longer leading the line. These entities are
following the true leaders in medicine science, physiology and the safety of the patient.
Chapter 5 –Dot Thinking
I spend a lot of time thinking about thinking. Why, because everything begins with a
thought. I am not the first one to say this but it bears repeating. Physicians especially need
to realize this fact. Thinking is the first step towards change. I want to be a part of changing
the standard of care in medicine. The definition of standard of care is “are you doing what

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most reasonable physicians in your area are doing?”. That definition forces physicians into
dot thinking.
What is dot thinking? If you put a small dot in the middle of a blank whiteboard or a piece
of paper and ask most people what they see, they will say they see the dot. Even though the
dot may only occupy 1/100th of the surface area as compared to the rest of the picture,
most people focus on the dot. Most people don’t mention the blank space that contains
infinite possibilities for creativity and more interesting objects and pictures to be
represented on the blank space.
As an ob/gyn for over 15 years, I was mesmerized by the dot. I only focused on giving
young women birth control pills for almost any menstrual complaint. Older women were
prescribed estrogen for any complaint (Pre WHI). If the women continued to complain, I
prescribed an antidepressant. If none of these therapies worked, the next step was to
remove any or all of the pelvic organs.
That was my dot. That is the standard of care dot for ob/gyn. My colleagues never
questioned me because they were doing the same thing. By default, this became the
standard of care.
Ask women if they think this should be the standard for their care. I have asked. I have
spoken in front of thousands of women and asked if this is acceptable. I always receive a
resounding NO. The loudest NO was from my wife when she began to have hormone
problems and was on the standard treatment. I was able to see firsthand how ineffective
the treatments were that I had learned and was prescribing to my patients. That experience
started my wife and me on a journey exploring the area outside the dot.

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We began to explore ways of testing hormone levels to guide treatment. We learned that
stress and cortisol affected hormones. We learned about how the gut and the
gastrointestinal (GI) system affect the metabolism of hormones. We rediscovered
physiology. We discovered ways to identify abnormal physiology and help the body restore
normalcy.
Furthermore, we are discovering how to detect and slow down mental decline associated
with aging. We have discovered how to run a practice that is above the present standard of
care. We have discovered how to have a practice that treats patients like human beings. We
have a practice that respects the patient’s time and the patients respect our time. All this
started because we took our eyes off the dot and began to explore the infinite possibilities
outside the dot.
Every specialty in medicine has a dot. Medical school, residency, medical specialty societies
like the American College of Obstetrics and Gynecology, and state medical boards all
strongly encourage you to focus on the dot of that particular specialty. There can be severe
consequences for the doctor who looks away from the dot.
Remember, I told you that I never got questioned or ridiculed by my colleagues as long as I
practiced dot ob/gyn. As soon as I started practicing differently, I was ridiculed by my
partner and had to leave my former practice. I was targeted by my hospital. I left the
hospital and stopped practicing inpatient medicine. I did this because I had the knowledge
and the courage to do it. Most doctors do not have the knowledge or courage to realize they
can survive outside the dot.
However, there can be huge rewards for the doctor and patient who explore other options.
I have never enjoyed medicine and the relationship with my patients more. I encourage
every physician and healthcare provider to take a moment and look away from the dot.
There are exciting experiences waiting for you there. The rest of this book will explore the
infinite possibilities outside the dot.

23
report the doctors that I have described to the state board because the doctor is harming
their pocketbook.
Doctors who go above and beyond the standard of care and offer the patient something
different and effective are attractive to the baby boomer generation of patients. The baby
boomers have always done things differently and rejected authority and the status quo. As
the standard of care doctor sees these patients go to the outlier doctors, they will use any
means necessary to stop them.
Another problem is that insurance companies are determined to keep physicians in the
bell-shaped curve. Insurance companies threaten and intimidate doctors if they stray
outside of the bell-shaped curve. Insurance companies enter doctors’ offices and coerce
them into signing in-network contracts. The insurance company tells the doctor that the
only way they can see the patients enrolled in their plan is to sign a contract and agree to
discount their fees by 30% to 40%.
The contract also gives the insurance company the right to discipline the doctor if the
doctor strays outside of 2 standard deviations of the bell shaped curve. This situation
effects the doctor and the patient negatively and the insurance company positively.
The doctor is forced to be ordinary. All doctors are doing the same thing. No one is doing
extraordinary work because there is no incentive to do more. If you do try to offer
something more or different, the doctor runs the risk of being audited and punished by the
insurance company. As the book Outliers and any other business book will tell you…”No
one values ordinary.” Ordinary doctors receive ordinary pay. Patients receive ordinary
treatment.
The insurance company is able to greatly control costs. The insurance company gets
discounted rates from the physician and can make sure the doctor does not order
treatments that can cost them money.
I enjoy being 2 standard deviations to the right. My patients enjoy being treated like a
person and not as a part of an assembly line. My family enjoys the fact that I am not
working all the time. My finances enjoy not being stretched to the limit. In this book, I will

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discuss the benefits of not being ordinary. But it all begins with how doctors think and how
doctors should think.
Chapter 7 – Be More like George
It is imperative that you understand that for anything to change in your life or your
practice, you must change the way you think. Also, you must take ownership of your

25
situation and understand that you are where you are because of the decisions you have
made.
It is not the insurance companies’ fault that you are where you are. It is not the
pharmaceutical companies’ fault that you are where you are. It is not your patients’ fault,
your families’ fault, the economy’s fault, and it is not the government’s fault. It is your fault.
You created the situation you are in. Now, think, how can I create a situation I do want. You
should be able to do that also.
I love to watch Seinfeld reruns. I watch them every day when I come home from work. If
you are familiar with the character George on the show, you know that he is a lovable loser.
He is Jerry’s best friend but not nearly as successful as Jerry is as a comedian.
In one episode Jerry and George are talking and George has an epiphany. George realizes
that all of his decisions have been wrong and have gotten him nowhere. He realizes that he
only has himself to blame. He makes the decision to do the opposite of what he would
normally do. Whatever naturally comes to mind, he would immediately do the opposite.
Can you guess what happened? His life made an 180o turn. Every decision he now made
was correct. He had unbelievable success. What happened was he did the opposite of what
he had been doing and he got the opposite results, i.e. success.
It seems simple. However, it is incredibly hard to do. It is difficult to stop and take a look at
your own actions and how the actions you do routinely almost without thinking could be
the cause your present situation. What is the present situation of most doctors? The 2014
practice profitability report states that:
 Physicians are more than twice as likely to anticipate eroding profits rather than
increasing profits
When physicians were asked why they had this negative view, they said:
 Declining reimbursements (60%)
 Rising costs (50%)
 More paperwork and less time with the patients

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The trend that the doctors were most excited about was increasing patient engagement and
spending more time with the patient.
Sixty percent of the doctors in the study complained about declining reimbursements.
What led to the declining reimbursements? The doctor signed a contract and agreed to
accept less money for their services. Why are the doctors’ costs rising? Because they signed
the contract they have to see more patients. This requires more space and more employees.
Why do they have more paperwork? The contract they signed requires them to submit
more paperwork in order to get the lower reimbursement. Why can’t the doctor spend
more time with the patient? The contract the doctor signed obligated him or her to see the
patients in the network and have the minimum amount of time to wait for an appointment
date. The doctor is forced to give minimum service to a maximum number of patients.
If one stops and thinks about this situation, it makes no sense. The problem is the doctor
does not have time to think and evaluate their situation like George did while talking to
Jerry. Another study in the magazine Medical Economics showed how doctors lost more
and more money each year from 2009 to 2012.
In its financial section, the survey found wafer-thin operating margins among those
physician practices. In 2010, only organizations in the western United States came closest
to breaking even, with an average loss of $27 per physician. By contrast, the Eastern region
averaged a loss of $1,597 per physician, whereas the Southern region averaged a loss of
$1,870. The worst performance was in the Northern region, with a $10,669 loss per
physician in 2010, which was even worse than the $9,943 loss per physician in 2009.
Do you know why? Every year when the doctor, the office manager, the accountant, and
even the practice consultant see that the profit margin is smaller at the end of the year, they
will all come to the same conclusion: we need to see more patients, hire more staff, and
open a satellite office so we can see more patients.
This is the kiss of death for a practice. This is George following his original thought and
decision-making process. This is the definition of insane: doing more of the same thing
expecting a different and better result. Doctors must make an 180o change in the way they

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With EMR systems:
a) You never misplace a chart. How much time is spent looking for one chart or pulling
and re-filing a chart after placing a piece of paper in the chart? Thinking differently
forces you to realize you are paying someone $10 an hour to spend an hour to find
one chart that you will be reimbursed $50 for seeing the patient. Subtract $ 10 from
that payment before you walk into the exam room.
o You have access to the patient chart form anywhere there is an internet
connection. You can view charts while on vacation, on your mobile device, etc.
o You don’t have to pay for office space to house chart racks. The space devoted to
storing charts is non- revenue producing space. Also, you have to pay for chart
folders, chart dividers and you have to pay someone to assemble the chart. All
these expenses result in less money for you, the owner.
b) Your EMR system should be accompanied by a practice management system. Learn
how to manage your practice with this system. Yes, you learn how to manage your
practice. The practice management portion will allow you to schedule patients, see
all your financial transactions, and evaluate your practice in all areas.
Take Control of Your Office
This leads me to my next point. Learn how to do everything in your office, especially your
office manager’s job. Traditionally, doctors think it is noble to say, “I just want to see
patients, I will let someone else handle the business part of the practice.” I have heard it
said a thousand times.
Let me inform you something: if you don’t pay attention to your business, someone else
will watch the profits go into their pockets. This is from personal experience; if you do not
carefully watch your business or have someone like a loving spouse watching your
business, it will not be consistently profitable.
If your office manager or administrator leaves abruptly, who is going to teach the new
person what to do? While you are trying to find someone else, what happens to your billing
and reimbursements? How do you know they are going to do things correctly? Who is

29
going to teach the new person? If you do not know how to run your own practice, and if you
don’t know how to evaluate your practice you are in a vulnerable position.
The vulnerability puts you in a weak management position. Because your office manager
holds the key to your cash flow, you become a hostage. If the manager makes demands or
threatens to leave, you cannot make objective decisions because you are afraid that if the
manager leaves, your money will be interrupted.
The solution is to never allow anyone in your office to know how to do something that you
do not know how to do or that is not in a written procedure manual. All businesses have
written policy and procedure manuals. How you want your office run should be written
down in a policy and procedure manual. This is important for a smoothly operating
practice but can be helpful medico-legally.
Most medical practices have a few staff that come and go. Verbal communication and
training does not work. Verbal training getsconfusing with time. Everything that takes
place in an office needs to be written down so any new employee knows what needs to be
done and how it should be done. Also, it makes you think about every aspect of your office
and ensures that the office reflects you and not the employees.
Create a Niche
You will go broke waiting for sick patients to walk through your door. There are
not enough sick patients to go around. Consider doing wellness medicine, which
widens the scope of patients to everyone.
When I was practicing traditional gynecology, I would see 20 patients a day, hoping that
someone would come in with a large uterus, an ovarian cyst, wanting a tubal ligation or had
heavy vaginal bleeding. If that did not happen, I was frustrated. No procedures, no big
reimbursements.
I would think to myself, “Why are these patients coming to the office? They are not sick.”
What if I could do more than tell the 20 patients that day that they don’t need surgery?
What if my niche was to take the people that were not “sick” and make them better?

30
So, well they stopped going to doctor after doctor. That is what I did. I studied wellness or
functional medicine. Functional medicine helps the patient function better.
Most patients are not hypochondriacs. They are not coming to the doctor to kill time. For
some reason, they feel like something is not right. I have learned that women are in touch
with their body. Most of the time, when a woman tells a doctor something is wrong, the
woman is right.
I created the niche of becoming an expert at identifying and treating hormonal imbalances.
Hormonal imbalances are the major underlying cause for most female problems. The 20
women I was seeing in a day may not have reached the disease state but they were
experiencing the symptoms of hormonal imbalances. Now, I could test and treat all of the
women that were coming into my office on any given day.
From that I discovered that the hormone cortisol that is released in response to stress can
be the cause of a myriad of common problems, like insomnia, gastrointestinal problem,
fatigue, anxiety, and depression. Once I learned how to test and treat cortisol problems, I
could help my patients function even better.
Then I learned how stress, antibiotics, antacid medication, yeast and parasites could affect
gastrointestinal function. I learned how to test and treat the gut so I could help that one
patient really become healthy. I used my obstetrical knowledge to understand how adult
heart rate variability relates to fetal heart rate variability. These discoveries continued and
I continue to learn every day.
I hope you understand that what happened is that I am not frustrated because the nail that
fit my hammer did not come into the office today. Now I have so many tools in my toolbox I
can help almost any patient function better physically or a better term is help their
particular physiology function better.
What this does for the business side of medicine is that instead of trying to do one big
procedure, like a hysterectomy, and then trying to find the next big uterus, I can have one
patient that is not sick but is not well and provide several different services.

31
Providing several services for one patient is better than doing only one procedure on
several patients. The quote from the Medscape article states it like this: rivers of money do
not run by doctors’, only rivulets. But add them up and you have a mighty stream.
Offer One-Stop Shopping
The best way to boost your practice revenue is to offer as many services as possible. My
rule of thumb as to whether a service is added to our office consists of 3 criteria:
i. Is it good for the patient?
ii. Does the procedure provide me, as a physician, good information that I can use
to help the patient?
iii. Is it good for my business?
The first two criteria must be met before I consider the business aspect. If it is not good for
the patient, I do not care if it is good for my business. My first priority is the patient.
Whenever the first priority is money, trouble will eventually follow.
When you practice medicine based on physiology, the answer to most questions are in the
physiology book. A physician just has to remember what they have already learned.
Socrates said, “Learning is remembering.” I just had to remember how hormones
functioned together, how the gut functioned and how the adrenal gland functioned. As long
as a patient is not legitimately sick, I can help them. I let the sick patients see the doctors
that are looking for sick patients. I am happy to see the rest of the patients who want to
become truly well.
Hire As Few Employees as Possible
Employees are your most expensive budget item. They cost much more than their hourly
wage. The payroll taxes, health insurance and vacation time increases the cost to you, the
business owner.
For just a minute, I want you to put yourself into the employees’ shoes. I had to do this to
understand what was going on in my office. I had a lot of employees whom I was paying. All

33
On the other hand, businesses are a separate entity from you personally. The business
should be able to generate money even if the business owner is not there. As a doctor, you
must begin to think like a business owner and avoid being self-employed.
Now, back to the employees; first, everyone in the office needs to understand how the
practice makes money. The employee also needs to know what activities they participate in
that generate money.
Our office has many services and most of those services do not require my participation.
Our office makes most of its money by performing in-office functional medicine testing and
functional medicine lab testing. We also make money from providing in-office treatments.
The three rivulets that support our stream of revenue are my time, my staff performing the
testing procedures, and the staff participating in the treatment. I am involved in providing
my time to evaluate the tests and the success of the treatment. I am paid for my time. My
staff participates in the testing and treatment. Those two rivulets can flow whether I am
there or not. Now my staff is producing income.

34
Now, how do you change that non-productive culture that I previously described? Simply
speaking, create a culture where everyone is rewarded based on practice profit. Profit is
made when you subtract expenses from the total amount of funds collected by the practice.
The most expensive line item in a practice is employee cost. The staff needs to understand
that their income goes down with the more employees the practice has to hire. Now, the
employees are not as interested in having more employees share the practice profit.
Decreasing expenses now becomes everyone’s focus. This incentivizes the staff to not
waste time or money. More patients on the schedule was viewed as more work but now it
is viewed as more money. Making sure the patients are offered all the revenue producing
services is a priority, not a chore.
The doctor now has productive staff that has bought into helping the business become
profitable and not expecting the doctor to generate all the revenue. Many parts of the

35
business can function without the doctor being involved. The doctor can now pay him or
herself, fund retirement and then share a percentage of the profit with the staff.
Now that you understand this concept, it is important to hire staff that understands and
buys into the concept. There are employees that like security and there are employees that
like opportunity. Employees that like security want to know how much they are going to
make and do not want to take any chances. Other employees that think that they can
enhance your productivity want the opportunity to make more money if they perform well.
We ask each potential employee would they rather take a higher starting wage or take a
lower wage to start but have the opportunity to make significant productivity bonuses? We
never hire the person that wants the secure higher starting wage.
That person is not going to fit in the culture that you are trying to create. A person that
wants to add value to the practice would love to be paid based on their contribution to the
increased success of the practice. This is a profit sharing plan you are offering the
employee. This is a great benefit. If the person is sophisticated enough in their thinking to
recognize the opportunity, he/she could be a good employee.
Pay As Little Rent As Possible
Let’s make it clear: you are in business to deliver a valuable service and be paid based on
the value of that service. You are not paid based on how large your office is or how
beautifully it is decorated. If a physician is offering a service and information that is helping
people get well, the patient does not care how your office looks as long as it is clean and
organized.
In a business, not only do the employees need to be productive, the physical office itself
needs to consist of revenue generating space. This is why computerization is so important.
Electronic medical records don’t take up any space. Paper medical records take up rooms
full of space and space which requires you to pay rent.
If you do not need medical space, do not pay higher rent because it is medical space. If you
are not using specialized medical equipment that needs special drainage or electrical

36
wiring, you do not need medical space. Regular office space or even a living space can be
used to practice medicine that focuses on wellness.
These are some basic business concepts that all physicians should think about. These are
business practices that are two standard deviations to the right. These are business
practices that are outside the caterpillar line and opposite of how most doctors think. The
only way to get a different result is to take different actions.

38
The other thing a lot of doctors do not know is how much each insurance company pays for
their most common charges. Most doctors that I have talked to do not look at the
explanation of benefits (EOB) that is provided by the insurance company. The EOB explains
what charges are being paid and how much they are paying.
When I began doing this some 15 years ago, I was shocked at how little I was being paid for
the services rendered. I often found that I was not being paid at all. Because I did not know
my business and did not understand insurance, I lost a lot of money unnecessarily.
I often saw patients that hadn’t met their deductible and my front office did not collect the
proper amount for the visit. They were lazy or untrained and only collected the co-pay.
That meant I collected $10 or $25 for a $100 office visit. My office mistake cost me
$75.00.Even when my office collected the co-pay properly, I often saw that the payment I
received plus the co-pay did not cover my overhead cost for that patient. I don’t think that
most doctors understand that if your overhead is not covered by the reimbursement
received, the doctor actually paid money to see the patient.
In the example above, if your overhead is $83 per 15 minutes and a Medicare patient or a
private insurance patient was seen that does not pay $83, the doctor paid to see that
patient.
I tell doctors that are in-network to start examining the EOBs from each insurance
company. I tell the doctors to not have any sharp objects nearby and not to sit by open
windows in high buildings. When the doctor realizes how little they are being paid, they
may attempt suicide.
A simple look at the numbers will help the doctor and the office manager make some
critical decisions. The decision seems simple but it is a difficult concept for most doctors to
grasp. If the contract with the insurance company is not helping your business, you have to
STOP seeing those patients, or you have to renegotiate the contract. Remember, not only is
the overhead not being met, the doctor is not making any profit. The goal of a business is to
make a profit.

39
Now that we have numbers to work with, it is easy to see that in order to make a profit, one
either has to lower overhead or take insurances that reimburse more. One solution is to
lower the overhead. The problem most doctors have is that lowering overhead is difficult.
It is difficult to quickly reduce the rent because most doctors are in 5 to 10-year leases. The
most expensive expense is employee expense. Because the doctor is seeing so many
patients, it takes a lot of staff to manage the patient traffic, phone calls and recordkeeping.
Solution number two is to stop taking insurances that do not cover the cost of seeing the
patient. This is a must. No matter what the insurance company says, you will not make a
profit by seeing more patients when you are losing money on each patient. If the number of
patients/hour increases, your overhead will go up. The office will need more staff and more
supplies.
Eventually, there will be a need for more space. The fallacy seems obvious, that you cannot
make a profit by seeing more patients when you are losing money on each patient seen.
However, at the end of the year, when the practice profit is stagnant or declining, the
answer to the problem seems to always be we have to see more patients.
Even when I read medical practice management journals, most of the experts advise
doctors to increase the number of patients seen. The professionals suggest adding
physician assistants and nurse practitioners.
Due to this advice and trend, nurse practitioner salaries have increased to over $94,000. In
2011, the average salary was $74,000 to $90,000. That is a big increase in overhead, not to
mention the benefit costs the nurse practitioner will expect to be provided. The nurse
practitioner will also need support staff.
This is another situation where you need to be like George and do the opposite. The correct
move is to cancel the contract you have with this insurance company and stop seeing those
patients. Stop contractually losing money! Algebra teaches that if you subtract a negative, it
is a positive. Math is math. Remove the negative and it will equal a positive. Adding more
negatives together equals a larger negative. This simple math concept that we all learned

40
by the 5th grade holds true in the business of medicine. No matter who tries to tell you that,
this does not hold true so don’t believe them.
I recently read in Medical Economics an article about challenges doctors will face in 2015.
Of course, declining reimbursements was one of the challenges. One of the solutions was to
extend hours to include early mornings, late evenings and weekends to accommodate more
patients. Again, the suggestion includes working harder and longer and neglecting your
family to add more negatives.
The doctor should evaluate all of the insurance contracts they have. Closely evaluate all the
EOBs and determine which insurance companies must be eliminated. Now remember, just
because the office cancels the contract does not mean the office can no longer see the
patient.
If the insurance is a non-HMO, the patient can be seen but now will be an out of network
patient. Out of network will have a different deductible, but the doctor can collect enough
money to cover cost and make a profit. I will explain Out of network in a later chapter.
Now, the doctor can spend more time with patients that have insurance plans that are good
for the practice. Some doctors feel bad about refusing to see patients with certain
insurances. What must be considered is that if you continue to lose money, your practice
will close. If your practice closes, no one wins. Not you, nor your patients or your family.
Also, seeing more patients for less time in a more chaotic office environment is not good for
any of the patients. It increases the chance of mistakes, which increases the doctor’s risk of
being sued for malpractice. There is nothing more stressful for any doctor than defending
themselves in a malpractice case.
Let’s review:
1. Know your per patient cost
2. Learn to read and evaluate explanation of benefits (EOB)
3. Evaluate and compare reimbursement and per patient cost for each insurance
company
4. If the reimbursement is less than the cost, remove the negative (subtracting a
negative is a positive).

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5. Spend more time with patients with insurance plans that are favorable for your
business.
And now number 6. Offer those remaining patients more services
Or, the office has to offer more insurance reimbursable services. In the book “Good to
Great” the author, Jim Collins gives the example of Walgreens vs. Eckerd’s drug stores.
Walgreens concept was to build stores convenient to the customer and increase per
customer profit. This means have each customer buy multiple goods and services at each
visit.
Because the stores were convenient (all on corner lots) customers visited more often and
Walgreens offered such a variety of items, customers visited when they didn’t need a
prescription filled. The customers that did need a prescription filled would most likely buy
something else while they were waiting on their prescription
This is the same concept used by fuel stations. Companies like QT or RaceTrac that sell gas
at the lowest prices do not make money from selling gas. They make money by selling
snacks and coffee. Business is business. Physicians have to offer more services. Services
that are insurance reimbursable are desirable.
Patients do not necessarily want to pay more money out of their pocket at each visit. If
there are more services that will benefit the patient, if the service gives the physician more
information to further help the patient, and the service is good for the business of the
practice, then it should be considered.
I am always on the lookout for insurance reimbursable tests and services that will allow me
to take better care of patients. There are a lot of non-routine tests and treatments a doctor
can provide that insurance companies deem reimbursable. Some services are more
necessary in some types of practices than others.
For the primary care doctor who routinely does not perform surgeries or other procedures
that reimburse at a higher rate, these added tests can double or triple the per 15-minute
revenue. If a doctor is receiving $300 per visit instead of $61 per visit, maybe the doctor
can see patients every 30 minutes instead of every 15 minutes.

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Let’s do the math: if a doctor could provide in-office testing that is relevant to the care of
every patient, through proper documentation and billing he could receive $300 per visit
instead of for example $61 per visit and see each patient for 30 minutes. In 7 hours, the
doctor could see 14 patients. The doctor would make $600 per hour and $4,200 a day.
If we look at the example of the $50,000 overhead, we calculated that it costs $83.33 per 15
minutes or $332/hour. Now the doctor is making $268/hour ($600-332) instead of losing
almost $90 per hour. By subtracting the negative of $90, the net gain is $358/hour ($268 –
(-$90) = $358.
Wait a minute. The overhead was $83.33 per 15 minutes! But since my staff only has to
process 2 patients per hour instead of 4, my overhead should decrease. I won’t need as
much staff, my waiting room can be smaller and my supply costs will decrease. I won’t need
that nurse practitioner or PA and I don’t have to work on weekends.
So, in simple words, think differently and be an outlier. Make a 180 degree change in
thinking and actions and you get the opposite result
Chapter 10 – Why Did You Sign Contracts with Insurance
Companies
In changing the way you think, you have to ask questions. You have to ask good questions.
You have to examine some things that seem to be a given. I was a young physician when
managed care began in the early 1990s. How most doctors understood the process was

43
that insurance companies would form a network of physicians that would be available to
the insurance company policyholders.
The physicians had to pass a credentialing process because the insurance company wanted
to make sure the doctors in the network were of the highest quality. In exchange for
excluding the less qualified doctors and placing your name in the insurance companies’
network book that policyholders received, the doctors were asked to discount their fees.
The doctors were also asked to allow the insurance company to be involved in managing
cost by determining what test, procedures and treatments were medically necessary. These
measures were supposed to increase quality of care because only the GOOD doctors were
included. Also, the insurance company convinced everyone that they had businesspeople
that could better manage the cost of healthcare than the individual physician.
That was the plan. I remember doctors panicking trying to sign the contracts with
insurance companies before the other practices were able to sign. Every doctor and
practice wanted to be included in the network of quality doctors. Of course, no doctor
would want to be kept out of a network of doctors that insurance companies have “vetted.”
Only a certain number of doctors were going to be included so the insurance companies
played to doctors’ fears of being excluded. Doctors signed contracts without reading the
fine print. Doctors did not read the bold print. I know this because I was one of those
doctors.
My partner and I panicked. My partner was scheming with other doctors to be in the
included group and beat the other doctors into the network. It was a crazy time. All doctors
feared they would not be able to see their established patients and would definitely not see
any new patients. It was either sign the contract with the insurance company or financial
ruin for the doctor.
If you understand the previous scenario, it is quite obvious why doctors signed contracts
with the insurance company. I am sure you can understand that controlling healthcare cost
was and is important. But let’s look at what has happened in healthcare since the early
1990s.

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Health insurance premiums have gone up. The goal was to decrease healthcare costs.
Looking at this graph, the stated goal has not been achieved. Healthcare cost for the
consumer has been on a steady rise. Premiums have risen 3 times more than earnings and
over 4 times more than inflation. Some would say that is because our healthcare system is
so high in quality and one must pay for quality.
We are far from the highest quality
healthcare system in the world.

46
Remember, the insurance company has businessmen running it and doctors that the
insurance company pays ,and these doctors are usually stockholders, making decisions on
medical necessity. The insurance company wants to increase its profits. That is the goal of
any business.
The insurance company does not increase its profits by improving the ranking of the
country’s healthcare system as compared to other countries. The insurance company does
not make money by decreasing the cost of insurance to the policyholder. The insurance
company does not make money by offering new innovative treatments. The insurance
company does not make money by increasing doctor compensation.
Therefore, they have no incentive to do any of these things. As a result, as you can see in
the two charts below that the income for primary care doctors has remained stagnant for
years. Insurance company profits are booming.

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Profits for insurance companies have steadily increased while profitability for physicians
have remained the same or decreased. The 2014 Practice Profitability Report states that
the percentage of physicians expecting to see a decrease in profitability in 2015 has
increased from 36% to 39%. The cause is believed to be rising costs and declining
reimbursements.
It is quite simple how this situation arose and why it continues. Due to physicians’ desire to
be a part of the network of physicians in an insurance plan, we agreed to discount our
rates. Most doctors saw this as a way to access patients. In essence, what we did was put a
price on cost of acquiring patients. In essence, we gave the insurance company a 20% to
40% discount on every patient.
That is expensive advertising. What physicians received in return is their name in the
provider book or listed on the provider website. This costs the insurance company nothing
but it costs the physician 20 to 40 cents per dollar reimbursed.

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Doctors expect declining reimbursements and increased costs each year. Each year, the
insurance company is going to try to decrease what they spend and increase their revenue.
This is done by decreasing what is paid to the doctor and increasing the number of people
paying premiums.
This means more people in the network that need to be seen. This also means the doctor
must see more patients and be paid less per patient seen. To see more patients, the doctor
needs more space and more staff, which means higher costs for the doctor.
Business 101 would teach that if every year your costs go up and your revenue goes down,
you will have to work harder to stay even. Eventually, if this pattern continues, there are
not enough hours in the day to see enough patients to maintain or increase profits. I have
seen doctors work themselves to death, trying to keep up with increasing costs and
decreasing reimbursements.
Doctors see no way out. What I have learned is that the reason you are where you are is
because of the decisions YOU make. You cannot blame anyone else. If decisions and acting
on decisions got you where you are, decisions can take you where you want to be.
If the contract is not favorable, the doctor can terminate the contract. If the doctor doesn’t
like seeing a lot of patients because there is not enough time to take good care of the
patients, decide to see fewer patients. Decide to do more for that individual patient and
refuse to discount your services.
What I suggest seems radical. I am simply saying, if something is not working, stop doing it.
Stop digging if you are in a hole. This is easy to see when someone else is doing it. This is
hard to see when you are in the hole, especially, when everyone else is also in a hole.
What happens is that all of your colleagues talk about how hard it is to keep digging and no
one comes in and asks the question why you are still digging. Also, what happens is that
when someone tells doctors I can help you get out of the hole, they won’t reach up and grab
the hand that will lift them out of the hole. They don’t believe it is possible to get out.

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It takes knowledge and courage to do this. You have to have the knowledge that there are
other more sensible ways to practice medicine. And courage is the power to let go of the
familiar. Just because your current way of practicing medicine and running your practice is
familiar to you does not mean this is how you should continue to practice.
All change is tough. All change takes courage. All change is uncomfortable. A quote by John
Maxwell states that until one can become comfortable with being uncomfortable, you can
never get better.
Chapter 11 – In Network, Out of Network
We just discussed why the doctor would sign a contract that pays less than the cost of the
service provided.
The cost of ignorance is huge. Doctors who CHOOSE not to learn the rules are ‘helping
insurance companies pick their pockets’, in the words of Karen Zupko. The doctor must
know the rules. I am not a certified coding specialist but I do understand some of the most
basic rules that I did not understand previously.

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We talked about the contracts that doctors sign and why they signed them. They wanted to
be able to see patients. Increasing the number of patients seen was the goal. The doctor
wanted to be on every insurance company’s network. The fear was that if they were not in
the network, they would be unable to see any patients with that particular insurance. This
is what the insurance company told doctors. This is what other doctors told the doctors
joining their practice. This was the accepted dogma.
This dogma was beneficial for the insurance company. The insurance company had most of
the leverage. The insurance company had the patients. The doctor wanted to see the
patients. The insurance company’s lawyers wrote a contract that allowed the doctor access
to the patients under certain conditions. The doctor felt forced to sign the contract no
matter what the reimbursement.
I will insert a pearl of knowledge at this point: any contract is always going to favor the
person or group that wrote the contract. The insurance companies didn’t pay lawyers
thousands or millions of dollars to write a contract that is fair. The insurance company paid
the lawyers to write a contract that favored the insurance company.
Most doctors signed the thick contract on the back page and never read one sentence of the
contract. How do I know? That is what I did when I first opened my private practice. I
needed patients no matter what. Doctors that choose not to learn the rules will get pick
pocketed. This is what has happened and this reality is causing many doctors to go
bankrupt or sell their practices to hospitals.
These are some basic rules doctors need to understand about insurance companies and
insurance policies. Doctors understand in-network. This is when the doctor signs a
contract. This is what I have been describing. When the doctor does not sign a contract, the
rules do not state the patient cannot be seen by the doctor.
The rules are that the doctor can see the patient but there is no contract between the
doctor and the insurance company. The only contract is between the insurance company
and the patient. The patient has a contract with the insurance company. The contract is that

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Most insurance policies have in-network and out of network benefits. Some insurance
policies do not have out of network benefits. HMOs do not have out of network benefits.
HMOs will not pay for any services provided by a non-network doctor.
The key is to know this information before the office schedules an appointment for a
patient. Usually, a policy with out of network benefits will try to discourage the
policyholder from going out of network. This is done by increasing the out of network
deductible.
Also, instead of having a consistent co-pay after the deductible is met, the policyholder is
asked to pay a percentage of the charges. Most of the time the insurance will pay 70% to
80% of the charges and the patient is responsible for the remainder.
Why would a patient want to use their out of network benefit if it is going to cost them
more out of their pocket? That is an excellent question. The only way the patient would be
willing to pay more for something is if there is perceived increased value in the service and
if the service is above average or excellent. No one is going to pay more for average. No one
is going to pay more for something if they can get the same service for a cheaper price.
The key is to be an outlier, not a part of the bell-shaped curve. You need to be unique. What
does Louis Vuitton have that causes a person to pay extraordinary amounts of money for a
handbag? The handbags are unique, hard to find, increased value is perceived and
delivered.
The in-network doctors by contract are encouraged to offer the same services to everyone.
The in-network doctors are encouraged to see patients every 10 minutes. Sometimes,
patients wait two hours to see a doctor for 10 minutes.
What if a patient waited 10 minutes to see a doctor for 2 hours? Would that have increased
value? What if during those two hours, tests were done that were not focused on telling the
patient that you are not sick but were focused on making the patient more well. That would
be out of the ordinary; that would be valuable.

53
What is an added benefit is that sometimes out of network is not more expensive than in-
network coverage. Because the doctor has not contractually agreed to collect all
deductibles and co-pays, the doctor can discount charges or even give away services.
Most in-network contracts forbid professional courtesy or any exceptions to the collection
of deductibles and copays. When the doctor is out of network, he or she is an independent
practice and can work with patients to fit their financial situation.
Out of network benefits usually have a total out of pocket amount that the policyholder can
reach. This means the total amount of money that the policyholder will pay for that year of
the policy. For example, if the out of pocket is $2,000, the deductible is $500 and after the
deductible is paid, the policy pays 70% and the patient pays 30%. If the $500 deductible
and the 30% paid throughout the year reaches $2000 the remainder of the charges are paid
at 100% of the allowable reimbursement.
What is the allowable reimbursement? All insurance companies decide how much they will
pay for a certain CPT code. CPT codes are how the doctor’s office communicates what
service, treatment or therapy was performed for or to the patient.
The insurance company decides the most they will reimburse for a particular code no
matter how much the doctor’s office charges for the CPT code. In other words, the doctor’s
office can charge a million dollars for a CPT code. If the maximum allowable
reimbursement is $400, it is the maximum the insurance company will pay for the CPT
code.
If the office is out of network, the office can bill the patient for the other $999,960 or write
it all off or bill for a portion of the remaining amount. If the office is in-network, the
remainder cannot be billed to the patient. The doctor must write off the remainder.
You must understand this point: the insurance company has a maximum amount that it will
pay for a CPT code but it does not have a minimum amount that it will pay. The insurance
will pay nothing for the code if the doctor does not bill the insurance company. The
insurance company will pay nothing for the code if the office does not remain persistent

54
through all of the games the insurance company will try to play in order to not pay the
claim.
If the insurance company allows $300 for a CPT code and the office bills $200, the
insurance company will only pay the amount billed even though the insurance company
would pay $300 if the maximum were billed.
Review
 If the doctor does not sign a contract to be in-network, the office can see the patient
as an out-of-network provider.
 Out of network means your charges will not be discounted.
 An out-of network practice needs to offer unique services and experiences.
Chapter 12 – Cash Only and Concierge Practice
The frustration of trying to get paid by insurance companies has caused many doctors’
offices to give up and refuses to bill any insurance company. The office has a policy of only
accepting cash for all services. The office refuses to even investigate the patient’s policy.
The office will usually give the patient an itemized receipt and a form for them to bill the
insurance company.

55
The doctor’s office, in other words, tells the patient to deal with their insurance company.
The patient is the one that has the contract with the insurance company. It makes sense to
let them deal with the frustration of trying to get reimbursed.
I completely understand this solution. There are only a few problems that I would like to
point out. As I pointed out in the previous chapter, if you are a cash-only practice, you are
an out of network practice. The designation out of network is a better description of the
practice than cash-only.
The reason why out of network is better is because it gives the office the option to bill a
patient’s insurance if the out of network benefits are favorable for the doctor and the
patient. This concept is initially hard for a doctor to understand. I will try to explain.
Refusing to investigate a patient’s insurance benefits may shortchange the patient, the
doctor and give the financial advantage to the insurance company. For example, the patient
calls the office and the receptionist tells the patient that the office does not accept
insurance. If the patient just paid her $1,000 insurance premium that month, the idea of
having to pay again may make the patient not come in to the office or delay coming in.
Think of that patient paying $12,000 a year for insurance and being told that it is worthless
in your office. The office may tell the patient that they can use the itemized bill to submit to
their insurance company for reimbursement. In reality, few patients will submit the forms
necessary to receive reimbursement from the insurance company.
The insurance company adds $12,000 to their balance sheet plus the amount that would
have been paid to the doctor or the patient if either one had billed the insurance company
for the services rendered. The patient is minus on their balance sheet the $12,000 plus the
amount paid to the doctor’s office, which on average is $1,000 to $2,000.
Because the doctor usually has to be much more cost-conscious, the doctor may not offer
all of the services the patient needs because it is all coming out of the patient’s pocket.

56
If a patient or the patient’s employer is paying a $1,000 a month premium, the benefits are
usually good. Most non-HMO insurances have out of network benefits. A policy with good
out of network benefits usually has these basic elements:
1. A low deductible ($1,000 or less).
2. Pays 70% or more of the allowable amount after the deducible is met.
3. Has a total out of pocket of $3,000 or less
Remember, if you are a cash-only practice or a concierge practice, you are also out of
network. This means you can bill the patients’ insurance. The difference is that you have
not agreed to any discounts and you can bill the patient for the difference between the
price you charge and the amount the insurance company pays.
If the person in my example has this type of insurance, the first visit would go towards her
deductible. Either the doctor’s office or the patient must bill the insurance company. This
notifies the insurance company that the patient paid money for healthcare services.
If no one bills the insurance company, the payment will not count toward fulfillment of the
deductible. This is a disadvantage for the patient with your office and for any other doctor
the patient visits for the rest of the year. The $1,000 is not documented. The patient will
continue to pay until someone bills the insurance company to notify them that the
deductible has been met.
If the insurance company is billed for the initial services and the payment is $1,000, all
other services will be paid at 70% and the patient will pay 30% of the charges. This allows
the doctor to do more for the patient. Cost is not that great of an issue. Now the doctor can
fully evaluate the health of the patient.
The third criterion is the total out of pocket. When the deductible plus the 30% that the
patient pays after the deductible totals the out of pocket (in the example $3,000), the
insurance company pays 100% of the allowable amount. In other words, the patient no
longer has to contribute towards the payment of services rendered.

57
This is really important if the doctor has initiated treatments based on initial findings. This
allows the doctor to retest later in the year without additional cost to the patient.
If you have a cash-only practice, not all patients have insurance with these types of benefits.
If the patient’s insurance does not met the criteria, then the doctor’s office should proceed
as usual and collect cash for services rendered. If the office never inquires about insurance
benefits, then the office never knows which patients have insurance that are beneficial to
the patient and the doctor.
Generally, patients at higher socio-economic levels seek unique health, wellness and
preventive medicine services. These patients are more likely to have employer-based
insurances with favorable out of network benefits. Doctors that provide these types of
services are the doctors that are usually cash-based practices. It makes sense to investigate
every patient’s insurance.
Concierge Practices
Most concierge practices charge a patient a retainer fee for a year of service. This fee allows
the doctor to be responsible for a small group of patients. This allows the doctor to avoid
having to see 20 to 30 patients a day to generate enough income to make a small profit.
The fee can be anywhere from $500 to $5,000, or more. A majority of doctors will offer 24-
hour access to the patients, including the doctor’s cell phone number. Usually, the fee is for
access and availability and routine care. Other testing and treatment is usually done at an
extra charge that is usually not billed to the insurance company. Again, it is the patient’s
responsibility.
My first problem with this arrangement is selling 24-hour access. I spent 16 years as an
obstetrician/gynecologist. As an obstetrician, I was forced to offer 24-hour access. Believe
me, it gets old quickly. As one gets older, one realizes that time is the most valuable asset
that one can control.
I do not sell my time cheaply. I will not sell my whole day to someone else if I am not
married to her or they are one of my two children, period. I spent enough time away from

58
the people I love while I was delivering babies. That is a personal aversion to the concept.
This may be something that other doctors don’t mind.
The second adjustment I would suggest is to understand all of your patients’ insurance
policies. If the patient is required to pay a retainer out of pocket, that amount of money
should be billed to the insurance company in order for that money to count toward the out
of pocket expenses for the patient.
This is important because it can count toward the patient’s deductible. When the
deductible is met, the doctor’s office can bill the patient’s insurance for services not
covered by the retainer. This means the insurance may cover 50% to 70% of the allowable
reimbursement. As described earlier, when the patient pays enough out of pocket to reach
the maximum out of pocket expenses, the medical services are reimbursed at 100% for the
rest of the year.
Understanding the patient’s insurance helps both the patient and the doctor. The patient
gets credit for the entire out of pocket expense. The doctor is able to fully evaluate the
patient’s health because expense is less of an issue for the patient. Now, the patient is
getting more value from their insurance.
I am bringing up these issues because I am trying to get doctors to not be close-minded
about how they think about their business. It is easy to make decisions based on a past
experience and overreact in order to avoid the pain. All doctors have had bad experiences
with insurance companies and attempting to get paid.
Many doctors gravitate toward new ideas that avoid the pain of trying to get paid. What I
am trying to get across is to not let the insurance company off the hook. The insurance
company should fulfill their obligation to the contract that they have with the patient.

How doctors should think? Who are physicians? How do they boost their practice? How they should think about Revenue Streams.

How doctors should think? Who are physicians? How do they boost their practice? How they should think about Revenue Streams.

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