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You've got to learn how to see patients in two or three different rooms. You have to see more patients. It's the only way you're going to maintain profitability.
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AUDIO - Rick Garofolo - HSP #132
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VIDEO - Rick Garofolo - HSP #132
Goal setting, why you should never haggle with patients about pricing, and how to stay OSHA and HIPAA compliant.
As the President and CEO of The Practice Mechanic, Rick Garofolo has contributed to the business of dentistry through proper accounting techniques, recall and follow up system creation, proper treatment plan presentation and more than 20 other systems.
In his newest book “Driving your Dental Business, 16 Business Lessons I Learned Teaching My Daughter to Drive”, Rick shares practice management techniques and methods that he used and still uses to grow dental practices’ bottom lines by an average 80% per year all over the country. Rick’s unique experience comes from a combination of years of successful business ownership with advertising agencies, PR ?rms, publishing companies, multiple magazines, restaurants, bakeries, a chain of barber shops and commercial and residential real estate investments coupled with his years of experience in the dental industry as a consultant and dental business owner.
Rick’s realistic, informative and inspiring speaking presentations are in demand nationally and internationally at seminars, dental meetings, and conferences. Rick’s presentations concentrate not just on the requirements, but also on how they actually tie in to everyday life in dental offices. He has also published hundreds of articles in industry publications nationally.
Working as a practice management and OSHA/HIPAA compliance consultant for dentists, Rick develops site speci?c plans and business systems for dental offices around the country, including state speci?c plans. This allows them to concentrate on working ON their business instead of working IN it, creating increased opportunities for pro?t and allowing dentists and practice owners to sleep well.
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Howard: It is a huge honor today to be interviewing Rick Garofolo, who has been doing dental business consulting for twenty years, ever since his wife graduated from dental school. How are you doing today?
Rick: I'm doing very well. How are you?
Howard: So your wife forced you into the dental industry.
Rick: She absolutely did. Yeah. She bought a dental practice. I had been in business previous to that. She bought the practice. We were working our separate businesses. She came home one day and said "You know, I don't understand what's going on. I'm working harder and harder and harder and not making any more money than I was when I was an associate." So I said "I don't know anything about dentistry, but I know business. Let me come in, take a look at your numbers and see what I can figure out."
Monday morning, I walked in at 8:30. Tuesday morning, after reviewing everything, I fired her front desk staff and office manager and I took over. I taught myself how to do claims, I taught myself the codes, I taught myself everything. Spent six months by myself doing everything. Hired a staff, trained them to do it my way. Long story short, we had a friend who is an orthodontist who said "Hey, you have a general dentist friend who needs some help, will you go look?" She was going through a divorce. I said "Sure, I'll take a look and see what I can figure out." Went to help her, talked to her for a couple hours, and that began my consulting career. Went pretty quick and I've been doing it ever since. One of my favorite things to do naturally is to work with dentists and teach people and talk about business. I love business.
Howard: Okay, so twenty years in the making. 56 hundred kids just graduated from dental school last month. What changes have you seen in the dental industry twenty years ago when you started helping your wife to today? Meaning, if your wife just graduated today and started this all over. What would be the difference of starting a dental office today versus twenty years ago?
Rick: One of the big things that we deal with every day, both with my wife and all my clients, the biggest thing we're dealing with right now is insurances, the regulatory issues that come along with it, and making the schedule work to be profitable while working on a PPO plan or even an HMO fee schedule. A lot of dentists twenty years ago, the norm you saw one patient, your fee for service, maybe it took a couple insurances but it wasn't that big of a deal. You could see one patient every hour and a half and still maintain profitability. Unfortunately, now it's not like that. I just had a conversation yesterday with a group of dental students who had just graduated. They said "What should we do?" I said "Learn how to work out of two or three rooms. Learn how to jump around and help more people in a day than you're used to, because that's A, how you're going to maintain profitability, and B, see more patients." That's what it's all about. Seeing the patients and maintaining a profitable business. They have to go hand-in-hand and a lot of dentists don't understand that.
Howard: Okay, you've been a dental consultant for twenty years. What would you say to the guy thinking "Maybe I should just drop all my insurance. Maybe I should drop all my HMO's and PPO's and just do Delta only, but other than Delta and indemnity insurance, just drop all PPO's". What would you say to that advice?
Rick: You have to look at your demographics. There are people that I know that we have conversations on the Dentaltown message boards every day about this. There are some people who can do it and make it work. There are other offices that, based on the demographic of where they're located and the people in the area, it would put them out of business. You have to know your demographics, you have to know the people that you're serving. There's a big difference between a dental office in Beverly Hills and a dental office in the middle of Kansas. You have to know your demographic. My suggestion would be don't do anything until you know who you're serving and you know who you're trying to reach. You know what your patient load is.
If you don't know that, if you're 95% insurance and you say "We're going to drop it today and move forward." You may have a struggle ahead of you. You're going to have to change everything. You're going to have the way you've marketed. You're going to have to change the way you present your office. You may have to add technology that people see as being a valuable service to pay out of pocket for. If you're going to maintain the same thing. One of the scariest things for people is change. I deal with it every day in my clients' offices when we're going to change something. They get so scared of change, they don't want to do it. If you're not growing, you're just going out of business and you just don't know it yet. You have to be continually adapting to the new things.
You've seen how much new technology since you've started practicing? People love new technology. Anybody who says "I don't care if you're taking a film X-ray or a digital X-ray." Either they don't know the difference or they just don't understand it. That's our job, is to educate them on that on what we're doing. My suggestion for dropping insurances, absolutely without question know your demographic. Some people can do it, some people can't.
Howard: Okay, so right now there's this dentist driving to work and she's wondering "Hey buddy, I'm in this town." What would be some red flags of saying you're more in a PPO market, and what would be some red flags that say you might be in a market where you don't even need insurance. Are there any rules of thumb or generalizations you can make to get this person thinking about their demographics?
Rick: It's hard to make generalizations, but the big thing I would say you have to look at is annual household outcome, you have to look at the number of children that the average household has. We look at the value of each property on specific mail carrier routes when we're doing an analyzation.
Howard: Do you do these analyzations?
Rick: We do. Analysis.
Howard: Analysis. If this woman driving to work wants to do an analysis with you, how would she contact you and what would that cost?
Rick: The prices vary. Normally we start anywhere from four to six hundred dollars just to start. We're going to pull a full demographic on the county, the town, and the metro area that they may be in. They can contact us naturally. Our website is www.practicemechanic.com. That's how they can get ahold of us or they can call us at our toll free number which is on our site.
Howard: What's that toll free number? Furthermore, don't get toll free number as a dentist. You don't have a smartphone and you can't make a phone distance phonecall, get rid of it. I have dentists e-mailing asking me what my toll free number is so they can call me and ask a question. I'm like "Are you out of your mind?" What is your phone number?
Rick: It's 888-367-1322.
Howard: Say it again.
Howard: And your e-mail is rick@practicemechanic. By the way, to my listeners, he doesn't pay me for that. This is not a commercial. These podcasts are free and there's no money changing hands. Don't think anything like that. If this person's driving to work, she can e-mail you and say "I have a private practice in 855044" Hey that'd be a great thread. Do one on me. I'm 85044. I'm Phoenix, Arizona. Everybody here calls it Ahwatukee. Would you mind doing that for me? Start a thread, because I started mine in '87. In '87, it's a different neighborhood than 2015. The new apartment complexes are now poor people. The whole neighborhood's changing. You knew it was going down when they let me move in. I mean, whenever you let a drunk Irish guy move into your neighborhood, you know the neighborhood's going to hell. I would love to see that on my own, because I'm 52, and I often wonder how it's changed from '87 to 2015. My goal is that the average boy born lives to be 74. I've got 22 more years, I would love to practice to the last day I was alive.
I worked all day yesterday, and my average emergency is a toothache and a quarter of them are going to get an extraction, three quarters are going to get a root canal or a crown. When someone calls you, what's your average dentist Tuesday? When your average client calls you. What I'm trying to feel out here is there is about seven thousand dentists listening to this but all they're all alone. This person's driving to work and she's wondering what set of problems are you dealing with, so she can hear like "Are these my problems?" And what solutions are you doing for them. The average Joe Monkey dentist calls you up, why are they calling you?
Rick: Usually they're calling me for one of two things: they're not happy with their staff, or they're not happy with their production. They're it. There's a couple different parts to business. You know, you have a book. Did it launch yet?
Howard: I'm pre-selling it. The launch is September 6th.
Rick: That's all about what business really is. Again, this isn't a commercial, but you really did hit the nail on the head because there's a couple important parts to business and two of them are your processes and your people. They're the problems. People either aren't producing enough for one reason or another, could be scheduling, it could be anything. Or they're people.
Howard: Let's focus first on people then we'll come back to production and process. What is the average staff person problem? They're calling you up because their staff is driving them crazy. I've always said that, when I went to college, I thought if you figured out geometry, calculus, trig, and physics and chemistry and bio-chemistry, and got A's in all that that it would be the answer to the universe. Now I've practiced twenty years and I haven't used any single thing they taught me in the first five years. Now, I tell my boys, if you figure out people, how they think, what motivates them, what leads them, what gives them purpose. I'd rather get an A in people and fail every science class known to man. That's the secret to the universe.
This person, again. They're all alone. They're thinking "Well everybody has this staff problem." What are the complexities of the dentist staff relationship that you're hearing?
Rick: The biggest problem people have is having a team mentality. Every time I get a phone call from a dentist who is having a staffing issue, they're having a problem because "My two front desk girls don't get along." Or "My hygienist and my assistant don't get along." Or "These people don't get along. I can't get them on the same page." Everybody has their own personality, everybody has their own goals, and hopes, and problems at home, and things going on in their life. That's probably the hardest thing that we face. Dealing with, depending on the size of your office, it could be four, five, ten, twenty different people and those twenty different personalities. For me, the big thing that I try and do is get everybody on the same page working towards a single goal.
I take the time. I don't know if you can see the background here, I'm in a hotel in Columbus, Ohio this week. Working with a client, very hands-on practice take-over kind of situation. That's one of things that I'm doing every night. I'm taking one staff member out to dinner. The staff member and myself, one on one, so I can learn about who they are personally. A lot of dentists say "Don't get involved." They don't want to know. There's a lot of things you don't want to know from a professional standpoint, but you have to know what motivates those people, and the only way to learn that is to talk to them. You can have a hygienist who is all about the bonus and hitting her goals, you can have another hygienist or assistant or front desk person who just wants to come in and be appreciated. They don't need the money, they don't want the money, they're not motivated money, which I personally don't understand, but they're not.
Everybody has a different motivation, so you have to figure out what it is for each individual person. Take whichever path you want to take, but we all have to get to the same destination. That's the problem with people. You're never going to get them all on the same path, you just have to get them all to the same spot at the end of the day. That's all that matters. Whatever your goals are, that you're hitting them.
Howard: Okay, so now is this your standard programming? Is your standard consulting package you go down there and the first week you're in the office and you take members to dinner at night or is this a special case?
Rick: This is a pretty standard one.
Howard: What is your standard consulting package?
Rick: Our standard consulting package is what I would say to be probably one of the normal practice management consulting packages. I hate to say "Normal" because everybody does things a little different. I've spent almost twenty years now learning different things that worked in systems and actually trying them out in dental offices all over the country. For me, the big thing is creating a team environment. Definitely, you need those systems in place. All the normal things everybody says.
Howard: Specifically, is your standard package you go in their for one week, hands-on, and then you come back one day a month for a year? Technically, what does it look like?
Rick: We have two different levels of consulting. We have our normal practice management consulting level, which that's exactly what it is. We're in there for a week, observing, watching what's going on in the first two or three days. Taking the dentist and their spouse or whoever may be out to dinner to talk about their goals. We move on, we work with the employees, we work with the staff, we're observing for a week. The following month, we actually come back for another full week. We do some training, we institute some changes, we put some monitoring and spreadsheet tracking into place. Then we're back between one and three days every month for the rest of the year.
Howard: How much does a year package like that cost?
Rick: I do month-to-month. I have never been a big fan of having to pay for a year at one time or commit to a year.
Howard: How much is a month?
Rick: 2500 a month.
Howard: So it's a 2500 dollar a month program?
Rick: 2500 dollar a month program for that one. Then I have the next level up, which is what I'm here in Columbus doing now, which is what we call our practice takeover, which actually has been very successful since we introduced it last year. We don't get a monthly retainer, we get a percentage of the net from the office and we manage everything. The dentist basically comes in, does dentistry and goes home. We manage the staff, we do the accounting.
Howard: And that's called the practice take over?
Howard: So you will take over a practice in perpetuity?
Rick: In perpetuity. Again, that's a month to month as well.
Howard: How long have you been doing that?
Rick: We introduced it at the beginning of 2014, and we now have eight clients who are on the practice take over permanently.
Howard: You're in a suburb, what is it? Birdsboro, Pennsylvania, is that outside of Philly? Did they ever get a football team?
Rick: The Philly?
Howard: I heard they were getting one. Our message board manager Howard Goldstein, he's from Bethlehem, Pennsylvania. He's a crazy Eagles fan. Anybody, obviously if they were intelligent would be an Arizona Cardinals fan, and I've tried to explain that to him and he doesn't get it. So you've got eight offices. Are these mainly in Philly in a certain area? Are they some urban, some rural? What if some guy's like in Salina, Kansas. Do these eight practices have any demographic in common?
Rick: They absolutely are all over the board. I have one who is in Beverly Hills. His zip code, when we ran the comparison, his demographics search, his zip code is 90210. I'm in a suburb of Columbus, Ohio now. One in a suburb of Philadelphia, one in Seattle. They all really spread throughout the country.
Howard: I want to go back to the specifics, I want to go back to people. I'm a dentist, so I get dentistry. I am one. The sad thing about dentists is we're just all the same. If you told me I would never do a root canal again, I'd probably start crying. When people say "Do you want to go play golf?" I'd rather pull four wisdom teeth. I can read about root canals, fillings, crowns, bone grafting, implants. I get all that. That's where our nose is. When you start talking about people, I know what they're going to say. They say "It's all fluff. It's all fluffy. You're talking fluff." I want to go specifically back to people. When you come into an office, dentists are always wondering, how do you if you can fix Margaret or you need to fire Margaret? When you come in the office that first week and they introduce you to the team, and you go to dinner with Margaret, how does your thinker work when you're meeting the staff members? Whether it's receptionists, assistants, hygienists, what are your cues to say this person's gotta go? I assume, 95 times out of a 100, we're dealing with women, right?
Rick: Most of the time, absolutely.
Howard: Almost every dental office you walk into. Mine's a rare dental office, I have a male office manager and two male dental assistants, but every one in the offices that I go into, they're usually all women because the dentist is a woman. They're all women and one man because the man's the owner. What is your go-to thinking analysis of whether this person's attitude can be turned around or she's got to go?
Rick: My biggest pet peeve, the biggest identifier to me on if somebody's going to be able to stay or if they're going to have to go, is if they "We've always done it that way." More than twice. I give them two times. If a third time you say "We've always done it this way." That's somebody who doesn't want to evolve, who doesn't want to change, who doesn't want to learn anything new. People get very complacent in where they are. I understand being afraid of change, I understand having that fear of what's going to happen if it doesn't work. At the same time, if you're calling me, there's a reason you're not happy with where you are. If you think things are going to change and your position is going to improve by not changing anything, they're the people that I can't help.
Howard: Now I'm going to ask you a delicate question, because you make your money from dentists. Dentists pay your bills, so I'm going to throw you under a bus right now. How do you make up your mind when you realize the staff's pretty normal, they're actually good, but dude you're a freak. How do you handle that situation? You listen to this dentist blame everything on Obama and the grease default and the Chinese stock market and Bill Cosby and the guy from Subway and you're just like "Dude, look in the mirror. You're a freak. You're the reason all the staff comes and goes, you're the reason." How do you handle that situation? Do you turn them down as clients or do you try to work with that person?
Rick: You look them in the face and say "You're the problem." Nobody is beyond repair, but we need to fix these processes. We need to fix these thought processes in your head that, most of the time, honestly you're a dentist, you know dentists, a lot of dentists can be very self-limiting. "I don't think I can do it, I can't handle more than two patients, I can't see more than one an hour." It's very limiting. It's a self-limiting belief that you need to get over. I'm a big believer in psychology. My daughter is on her way to the University of Kansas to major in psychology because I talk about it so much.
Howard: That's one of the best universities out there. I'm from Wichita, Kansas. K.U. is one of the most amazing, biggest hidden diamonds out there. It's 35,000 student body. That is an amazing university.
Rick: I was actually there last week with her for orientation.
Howard: In Laurence, Kansas?
Rick: Right in Laurence. She loved the campus, everything is great. She's looking forward to it and she's learning the Rock Chalk chant, so we'll see how she does. I'm a big believer in that. I actually just today, this afternoon before our appointment, I went for a walk with one of the front desk girls at the office I'm working with this week. We just went for a walk along a hiking trail next to a river and talked about all the things going on. She was harboring so much anger and resentment and she had so many pre-conceived notions based on her life experiences that she was actually affecting the practice.
You have to be able to help people as a boss, as a business owner, as an employer. You have to be able to help people, on some level, get past these things. Everybody has them. She was a single mother, didn't have a lot of money to raise her kids, her ex-husband never helped. She was angry, she was upset. When she'd see a single mom come into the office, we have to give them a discount, we have to give them a break. Don't worry about charging them for a missed appointment which I hate anyway, but they did it until we changed it. We have to do this, we have to do that, we have to help her, we have to do this for free, we have to do that for free.
Meanwhile, I spoke with the single mother she wanted to give a discount too yesterday who is doing very, very well selling advertising on the radio station. She's the number one sales rep. She's making four times as much money as the dentist made last year, and we're giving her a discount because she's a single mother because of a pre-conceived kind of psychological--
Howard: There's going to be about 7,000 individual dentists listening to this. Dentists all believe they walk on water, they're perfect, it's always somebody else. I want you to start talking to this dentist right now. What are some red flag examples you could be telling this dentist right now that he's part of the problem? What are red flags that, dude, you need to change and you can't blame everything on everyone else?
Rick: If their initial reaction to every single problem that comes up is "I need to fire somebody. I need to scream, I need to yell, I need to holler. I need to get upset. Somebody needs to fix this. Why does this happen? Why does my staff always do this?" When I hear somebody say "My staff always does this." It's not the staff. If they always do it, then you should expect it. You have to change, you have to set the priorities, you have to set the goals. You set the expectation. You have to do that. When you come to me and say "They always do this. They always do that." For me, that's a huge red flag, and that's what would I say to people who are listening to this. When you talk people, do you say "they" or do you say "we"? That's a huge part of it. You're the owner, you have all the liability.
They can walk away and get new jobs. You have all the risk, there's no doubt, but you have to still be part of the time. So many people elevate themselves above their staff and say "I know what I'm doing. I'm the dentist. I went to school for this." I don't know very many dentists. There are a few out there who were smart, who are not only DDS's but also MBA's and took the time to learn about business. There's a lot of people who don't. There was just a post on Dentaltown, a guy settling on a practice two weeks from now, and he said "I don't know what to do for payroll." Somebody said there's a payroll company, "Oh, I never heard of that before." And he's going to be a business owner in two weeks, and he didn't know there were companies out there that did your payroll for you.
Howard: I've got a beef with you though. I'm a big fan of your posts. You've got a couple hundred of posts on Dentaltown and thank you for that. I am a big fan and it's honor that you're on the show. When we're talking about tracking success using a board, why do Dentrix and Eaglesoft not do payroll? Why don't they track all this stuff on your board? Could you imagine going into any business and their insurance and billing and customer CRM wasn't connected to payables, receivables and profitability?
Rick: I've been trying to talk to the developers of those practice management softwares for years to get some type of integration.
Howard: So you agree?
Rick: Oh, absolutely! I think it's ridiculous that as a business owner, you can't go into your practice management software and say "Okay, I did a crown on Sally. How much money did I make?"
Howard: I know! How is this 2015? I can remember when I was six years old watching Neil Armstrong land on the moon, and you can't do payroll? Are you shitting me? Furthermore, when you do payroll, who cares if an accounting service does the payroll or your grandmother does the payroll, you're still not figuring payroll as a percent of your labor, your cost, your collections. You're paying a hygienist forty dollars an hour and she's billing out a hundred dollars an hour. Where's the report to show you that you're losing money on a claim? How come when a doctor is looking at a PPO schedule, he can't enter the fee schedule and it says "You take 1 hour to do an MOD composite and this fee for that is 280." Your operatory, just for rent, mortgage, billing, insurance, everything is 285 an hour.
So every time you do a filling you'll just take a 5 dollar bill and go shred it. Most dentists would say "Well hell, a filling is hard to do an awesome MOD direct composite. I'm not going to do that and throw five bucks away." I think half the consultants are in business today, because the Dentrix, Eaglesoft, SoftDent, you're somewhere between Stevie Wonder and Ray Charles when you're using those systems. To call them a management information system means you don't even know what the word "management" means.
Rick: Absolutely. I do agree with you. I think that's why there are so many consultants in business today because it's very difficult. You're a busy guy. If you were on your own and a solo practitioner and had just the office staff and no other help, you wouldn't have time to spend the hours and hours a week developing the spreadsheets and filling them out. All the things that we do kind of behind the scenes automatically to generate that one report that shows everything together.
Howard: What software developers have you talked to? Which systems?
Rick: Very much Eaglesoft. I'm actually an Eaglesoft trainer.
Howard: What is their response to you?
Rick: It's not viable. The profitability wouldn't be there. We can't compete with quick books. I don't understand. Make a bridge that actually works.
Howard: You can cut and paste accounting software off the internet. All that code has already been written. Accounting was invented five hundred years ago. There hasn't been anything new in accounting, just as there hasn't been anything new in geometry or algebra or addition or any of that stuff. Talk to us about your board. You're in the board. Talk about your board.
Rick: When I started out I owned an advertising agency and PR firm. I took a lot of different sales training courses to sell advertising and to get new clients. I actually became a Sandler-certified sales trainer, which Sandlers is one of the big sales systems out there. I went into a number of different businesses to do sales training. One of industries I got booked in was car dealerships. If you walk into the office of a sales manager at a car dealership, they have what they call "The board". Which is a big, white, dry erase board that has every salesperson's name and what they've sold this month so far, what they sold last year, all their information toward meeting their goal.
We do the same thing in a dental office. We put up a big, six-foot-by-four-foot white board in the conference room or break room or wherever, and we put everybody's production up there every day. We put what our collections were, because we're all working towards the same goal. There's a lot of dentists who say "I don't want them to know what I collect. I don't know want people to know what my totals are or what I produced." Whether they think they make too much money or not think they make enough. When you have a team, you share that information. We put that up on the board and it keeps everybody's mind on what it should be on. I can look at that board and know I hit 106% of my goal yesterday, I hit 87% of my goal yesterday. The practice management software, they all have it in their calendar and appointment book. It's in there, if you look at a month at a glance or in different places, they all have them. This really puts it out in front of everybody, makes it real.
I'm amazed when we go into an office and we put up a board, how often people will run back during the day to look at the board. "What did I do? I only need eight more hundred, I only need six more hundred, I only need another twenty five dollars!" I really got to get that person [inaudible 00:33:10] at the end of the day, not only have they not had them in two years, but it will help me hit my goal. It brings that to the forefront of everybody's mind. You put up that board and you share that information.
Howard: Are you a believer in the morning huddle? Do you go over the board at the morning huddle?
Howard: What percent of your offices do you recommend a morning huddle?
Rick: I want it in 100% of them.
Howard: What is the mechanics of that? Ten minutes? Five minutes? Half an hour? Does it involve the board? Who gives it? The office manager or the dentist?
Rick: Usually the office manager will give it. If the practice doesn't have an office manager, then we have whoever's assigned to be the scheduling coordinator, the person in charge of the schedule. She or he is going to be the one who's going to say "Listen, this is what we did yesterday. You hit your goal, you hit your goal, you were this much short, we need to do this, we had a couple holes, here's the reasons why, here's what's happening today. What do you need from me? You are 200 dollars short. Do I need to mention to somebody about fluoride? Do I need to mention somebody about sealants? What do I need to do to help you treat your patients better?
I'm not suggesting we sell things that people don't need. I hate when people think that. You should never sell something somebody doesn't need. I truly believe that half of our job is helping people get out of their own way and convincing them to get what we know is in their best interest. So many dentists say "Well, I told him he needed a crown, he didn't want to do it. Guess what? It's six months later. The tooth is broken and now he needs an extraction or a partial or an implant." An ounce of prevention and a pound of cure. Same thing. We have to help people get out of their way. At the morning huddle, that's when you discuss what needs to be done, who needs what, what needs to be done, all goal-oriented.
Howard: More specifics. After the morning huddle, are you a fan of everybody wiring up to Motorola walkie-talkies or are you not a big fan of that? What are your thoughts on that?
Rick: I would say that right now I have about 50% of my offices who have it. The ones that have it, love it.
Howard: We love it. We could never go without it.
Rick: You hit a button and you can find out can they have [inaudible 00:35:38]. One of my biggest pet peeves is leaving a patient alone. I don't think you should ever get up, walk away and say "let me go get the doctor" because then you go away, you go get the doctor, you stop for a drink, you stop at the doctor's office, he's looking at a video on Youtube. You end up being gone for five minutes before you even know you've been gone. Meanwhile, they're sitting there with nothing to do, waiting for you. Five minutes in a dental chair waiting for the dentist to come in seems like twenty minutes to people.
Howard: You're going to have cancellations and no-shows, but what I like about it is you can have four ladies up front on the desk and someone gets a cancellation for an appointment in ten minutes. She says "Howard, ten o'clock in room eight just cancelled." The three ladies sitting next to her might be talking to a person on the phone with an emergency going "Oh my god, can you come down right now?" All hygienists immediately look at the patient's chart like "Oh, Rick Garofolo, you need to have a filling done. Right after the cleaning, we can move you right to Dr. Farran." One hygienists doing cancellation, and the other hygienists doing [inaudible 00:36:51] and she just looks down and says "Hey Rick, we've done one quarter. You want to just stay another hour and do another one?" Then she's right back on it. It's so fast. It's lightning fast.
I'm going to ask you more specifically about your goal. Let's say your goal is 4,000 bucks, and your 11 o'clock 1,000 dollar crown cancelled, and now 11 to 12, that room is empty and you were supposed to be in there doing a crown. Then an emergency calls and they can get down there in forty-five minutes but lunch is 12 to 1. Would you say "Okay, we just got a cancellation 11 to 1. Go in the break room and find something to eat because I just scheduled a crown on your lunch." Some staff would go get a Gracy 1-2 scaler and carve out your frontal cortex, and other staff would just say it's part of the job.
What about this, Rick? Specifically, my four o'clock patient cancelled. We close at 5. It was for a crown for a thousand. Now I'm going to miss my goal by a thousand. Someone just called and they've got a toothache but they can't get there until 4:45 or 5 o'clock. Do you go home and miss your goal of a thousand or do you go long and say "Sorry, we were going to go home at 5 but we got a toothache." Do you make goal one day at a time, even if it's missing lunch or going home late or do you make it up the next day?
Rick: Absolutely, you stay. I don't know very many doctors who can leave. I don't know any heart surgeons "You know what? I'm in the middle of this operation, but it's 11 o'clock. I got to go. I've got 11:45 tee time. I have my golf league at 5:45 and it's 5 o'clock. I've got to get out of my scrubs and go!" Nobody else does that. For some reason, dentists have become susceptible to the staff whims of "It's five o'clock, we have to go." That doesn't matter. Our job, first and foremost, is to treat patients. If it was your mother, would you want them to be told "Sorry, we'll see you in the morning" or would you want them to be told "I'll see you now. Come here as soon as you can get here."
Howard: I posted on my Facebook page a couple of weeks ago. I was at the park, about a month ago. One of the hikers fell down and couldn't get up. Someone called cellphone 9-11 and a firetruck was there immediately. I told the Fireman "You know what? It's a good thing she fell down and needed a fireman, because if she had a toothache and needed a dentist in Phoenix, Arizona? You could find a pound of heroin before you could find a dentist on Sunday. You could probably find an AK-47, a pound of crack cocaine. Finding a dentist on a Sunday? I told her I'm glad she broke her ankle and not her front tooth. I agree.
Rick: That just goes to what in my opinion has been dentists allowing the industry to turn into the flea market of the medical world. Nobody walks up to a neurosurgeon and says "Hey, I need this 25,000 dollar operation but I'm paying cash. I'll give you fifteen, how's that?" Nobody does that, but how many times do you get a patient that walks in and says "Hey, I need five crowns that are a thousand bucks a piece. I'll give you 3500 cash money and you do them now." It happens all the time because we allow patients to do that. They don't do that to anybody else. You don't even go to Wal-Mart and say "I see you want forty-nine cents a pound for bananas. I'll give you thirty-eight cents a pound, how's that?" They do it with us because we let them.
Somewhere along the way, dentists stopped thinking about themselves as doctors. That's what I say all the time. When I teach a seminar, people will say "Patients don't expect that." I'm introducing myself to a new dentist, "Hello, doctor, how are you?" "Oh, don't call me 'doctor', my name is Howard." Your name is doctor. You went to school. You earned it. I don't know very many other doctors who will say "call me by first name." For me, it's a respect thing. Once I become a friend, absolutely I'll call you by your first name. However, we have to expect to act like medical professionals, and part of that is being on-call when a patient needs you.
Howard: I thought it was always fun. My business card has got my cellphone number to my iPhone and my e-mail address. I had four boys growing up. Whenever someone called, I'm three miles from my office, I'd just say "Boys, daddy's got a patient. Have an emergency." They'd run for the car. I made it fun. One would get the patient bib on, one would try to find the mirror, every one of the four boys had their task. Of course, I'm obese, so after the emergency for a reward we'd all hit the Dairy Queen and have a big Sunday and talk about how we helped that lady. I'm a big fan of one of your posts on Dentaltown where you talk about using proper coding to increase patient benefits in your bottom line. What do you mean when you say stuff like that?
Rick: There are a lot of things that we can do in a dental office when we're billing services out. One of the most misused codes that everybody has is that D0140 which every person in the world calls "an emergency exam". It's not an emergency exam, it's a limited. People use that and then you have to understand here's what happens. Insurance companies put a limitation on the number of exams a patient can have a year. They can, in most cases, have two exams per year. If I come in February for a recall, you do [inaudible 00:42:57] and exam, D0120, I've used one exam.
Howard: When you say "D0" is that D letter O or D zero 140?
Rick: It's D zero 140.
Howard: Okay. You can do two of those a year.
Rick: You can do two exams a year. Most people use those two exams at their recall. Then you get a patient who walks in the door who has an emergency and people bill out that D0140. Now when the patient comes for their second recall, you've hit your frequency limitation for exams. You're only allowed two per year. Now, the patient has to pay out of pocket. The number one reason people stop going to a dentist or look for a new dental office is over money. If we can avoid an issue, we do. I always say, there was a code made for an emergency. They tell you right in the code, this is the emergency code. It's 9110.
Howard: Is it really 9110?
Rick: It really is. That's a palliative treatment.
Howard: Oh my god, 9110. I didn't even know that was the code for the emergency. Does that have any relation to the phone call 9-11?
Rick: I don't think so. I think it's just an amazing coincidence, but that's the code. Why would you use a patient's exam frequency, trigger that frequency limitation, when you could just as easily bill for a palliative? Which actually pays a little more than the exam code and doesn't limit the number of exams the patient can have that year. You bill for the palliative, they're happy, there's nothing out of pocket, there's no added expense of a frequency limitation on a recall and everything is good. They're happy and you do it properly.
There are probably a hundred codes that are so misused or underused that people just need to know what the codes are. There are so many dentists who don't even know the codes. Realistically, you don't have to. You go out to your front desk or you go into your practice management software and you click a button and it says "We did a crown. We did a PFM or a full porcelain." You don't have to know it's 27-40 or a 27-52, but somebody in your office has to know this and have to know what the guidelines are. There are so many ways where we can increase a patient's benefit by billing properly. The less we can give the patient for an insurance office, the less we give a patient out of pocket, the more treatment they can accept. I don't care who you are, most people have a limited amount of money. I have a limited amount of money, you have a limited amount of money.
Howard: I have a limited amount of money, but my ex-wife doesn't.
Rick: Well, there you go. We all have limits, but they may be different limits. We have to help the patients, that's our job. That's why you have people at your front desk, to maximize the benefit for your patient. You're actually doing things more legally by doing it the right way and the way you're supposed to than what a lot of these people do.
Another thing a lot of people don't know. A lot of dentists will say to me "We use the comprehensive new patient exam code for every new patient, whether they're in the hygiene schedule or the doctor's schedule. They're coming in for an emergency as a new patient. We use the new patient exam code." It's not a new patient exam code, it's a comprehensive exam. If a patient comes in for an emergency, are you doing perio-charting on them? Are you recording all the dentician if they have an abscess in your chair if they're coming in as a new patient for an emergency on the doctor's side? Most offices aren't. You can't bill for a comprehensive exam if you didn't do perio-charting and recording of all the dentician. That's what a comprehensive is. It's just knowing what the codes are that allow you to bill properly, and by billing properly, you're really maximizing their benefit. You're cutting down their out-of-pocket.
Howard: Hey Rick, talk about your book. You wrote a book, "Driving Your Dental Business: Sixteen Business Lessons I Learned Teaching My Daughter To Drive" Everyone wants to know, did she ever learn how to drive?
Rick: She did. It took a long time and I will tell you what lesson number sixteen. Lesson number sixteen is hire a professional. That's what I ended up doing. I gave up and hired a driving coach who taught her how to do it.
Howard: You know what? I really wish that would be the title of your first online CE course on Dentaltown. I wish you would make an online CE course, because I think it's hard for dentists to not know who you are, not see your face, not hear about you. I think if you did a one-hour online CE course that this dentist could watch in his office, you know? Get a couple pizzas. We all watch you, you teach us something. I think that deconstructs the sales process of going from "I need to hire a consultant, I need help." To "Who is this guy?" Talk about your book. I'm hoping to promise two things for you. Dentaltown, we started a podcast section.
The next section coming up is going to be the audio book. I don't know if you're up for it, but I would love it if you would go send me that book in an audio file. What's really crazy about these podcasts is they're multitasking, they're mostly commuting to work. Most of these dentists have an hour commute to work, to or from, and/or they do the treadmill or whatever the hell. They're multi-taskers who said I would love for that to be an audio book. What made you write that book?
Rick: What made me write is was I had been doing the consulting and been in business management for twenty years. About five years ago, I started doing continuing education classes. I started speaking at dental meetings, and then I moved in from speaking at meetings to doing self-sponsored seminars all over the country. I actually spend about forty weeks a year on the road speaking at different dental meetings and doing self-sponsored seminars all over the country. That has quickly become one of my favorite things to do, teach.
Howard: If you want to teach more, you know why you should do an online CE course? Because there's 250 dental societies in America and they always look for volunteers. Three dentists raise their hand, they say "okay, you're in charge of figures for next year." Then they say "We want one from endo and practice management and oral surgery." Then they go to Dentaltown, where all the courses are one hour, they'll go to the endo deal and they'll say "Okay, eight guys get one hour." They watch all those eight and the guy will really say "I really liked the fourth one." Then they'll call and tell you.
One guy put up a one-hour lecture on endo and booked 76 invitations to speak on it. If you want to speak more, make it so under the practice management. You have an hour. All those speakers come in, they don't know who these people are. They're always given these instructions. Get someone new. Don't have the guy we had last year, find someone new. I hope you do it.
Rick: I will.
Howard: What's the low hanging fruit of that book?
Rick: The low hanging fruit is there are so many business lessons in every day life. Everywhere you look, there's a lesson to be learned. That's what I say in the first page of the book. I spent six months trying to teach my daughter how to drive and ended up hiring a professional. I learned so much more than I taught her, spending that time one on one with her in the car, being in the passenger seat. When you're in the driver's seat, you get distracted. There's a lot of things going on. There's a million different things to pay attention to. When you take a step back and you sit on that passenger seat for the first time. Since I was eighteen, nobody has driven me other than me. I'm not a good passenger. This forced me to give up that power, take a step back, and to look at things almost from above and not be so detail-oriented on every little thing that's going on around me like "What's the speedometer, what's happening there, what's in the mirror, what's over here?"
I could just watch her and I could watch how she reacted and get a fresh perspective on it, and that's the big thing. The biggest point I want to get across to people, and this is my favorite chapter in the book, is there's a reason the windshield is so big and the rear-view mirror is so small. You have to look at where you're going. You have to remember the past. You have to have a little bit of "Let me look back" and see what worked and what didn't. Maybe what I want to learn and what I don't. If you don't learn from history, you're destined to repeat it. At the same time, you have to focus on where you're going. That's the most important lesson for anyone.
I talk to people who say that advice when I was reading that and thinking outside of practice management, thinking about my marriage. We spent so much time fighting over things that happened five years ago, we stopped looking at where we were going and ended up crashing. It's advice for every aspect of your life. Look at the past, but don't concentrate on it. That's why the windshield is so big and the rear-view mirror is so small, because that's where you're supposed to concentrate; on the future and where you're going, not where you've been.
Howard: I'm going to throw a one-liner at you and see how you react to this. There's people out there saying that the bottom line is if you want to do a dollar's worth of dentistry, you've got to present three dollars to treatment. There's other people saying that if you present your dentistry right, every dollar dentistry you present, you're going to do a dollar of dentistry. You've seen hundreds of dentists present treatment. What are your thoughts on presenting treatment?
Rick: You have to use the tools you have. I agree with if you present it properly, you present a dollar, you do a dollar. That may be 95 cents, maybe not a dollar. But I'll take 95 cents out of every dollar every single day. I'm okay with that. It's all in your presentation. I hate when I hear a doctor say "Do you want to do this?" I don't ask anybody a yes or no question. You have to re-train your mind on how to speak to everyone. I talked to a waitress in a restaurant the same way I talk to my wife, the same way I talk to my clients, the same way I talk to a patient in a client's office. You don't want to ask yes or no questions, and you want to present things the proper way so that they can understand why it's important to get it done. That's the battle.
I don't think you have to convince people that you're a good dentist. They're coming to you because they trust that you're a doctor and you know how to do a crown, a root canal. They understand that. They need to understand why spending that 350 dollars on their co-pay for a root canal is more important than getting another tattoo or putting a loud muffler on their car. That's what we have to overcome. By presenting things properly and using all the tools we have at our disposal, you can do that. Use your intra-oral camera. I can't tell you how many clients' offices I walk into that they have a camera at every operatory and they're covered in dust. "When was the last time you used this?" "Oh, we haven't used those since they got put in." Why did you buy them?
Use those. Put that hole in that patient's tooth up on a 27 inch TV that's huge so that when you walk in the room as the doctor, the patient goes "Hey doc, do you see what's on my tooth? You got to fix that" make them sell you on how to fix it, because that's what you want. You want them to be driven. You just have to give the patients a reason to be driven to get the treatment. They know they need it, but there's so many other things that get in our way every day, it's hard to pick what needs to be a priority. It amazes me every day when I walk into dental offices and I hear "Well, our patients don't have any money and our patients don't have this or that."
If you walked into an emergency room because you fell off a cliff while hiking, and they say "Hey, you're going to need a CAT scan." And you said "I don't have the 2500 dollar co-pay for that, are you crazy?" What are they going to do? They're going to kick you out. You need to leave. If you're not going to get what we need to help you, there's nothing we can do for you. We don't do that because we don't want to lose a patient. We don't want to give up a recall.
Howard: I agree so much. If someone comes in with a toothache, I'll say "okay, we need to do a root canal and we need to do it right now." Because in my twenty years, I've seen root canals go from pain to swollen to hospitalization. The tooth is coming out right now, or we're saving it right now. You need to make a decision. You have an infection, these can go crazy. What do you want to do? Remove it? Save it? I need to know what you want to do. It's that authoritary voice, let's do it.
Howard: I'm going to ask you this. Some dentists think that if you want to present treatment, you should hire someone to do it. You should get a treatment coordinator. Other dentists say "Oh, hell no. I want to do that myself. I'm the doctor." What are your thoughts on the doctor presenting versus the treatment coordinator?
Rick: I don't ever want a dentist talking money. Never, ever, ever.
Howard: Okay, but why?
Rick: Because in a lot of peoples' minds, if I say to you "Okay, I need a crown, how much is it?" You can tell me "It's a thousand dollars" Now, you just want my thousand dollars. You, being the dentist, should talk about "You need this because". "You need this because I've seen it go from you need a root canal, to infection, to hospitalization. I've seen it because this can happen, it can hurt you, it can cause this, you could lose the tooth, you could end up in the hospital." That's why you're there. Let somebody else worry about the money.
The moment you say "A crown is a thousand bucks" all they hear in their head is "That doctor wants my thousand dollars. He must need to make a payment on his kid's college. He must need to buy a new set of tires for his Mercedes." I don't ever want the dentist to be the money person, because then your patients think of you as the money guy. Let somebody at the front desk do that. Let a treatment coordinator do that. Let them talk about money. I tell all my clients, when a patient comes to you and says "Hey doc, how much is a root canal?" I don't know, because I don't base my decisions on how much something costs. I base my decisions on what is best for you, the patient, medically. Not how much something costs. I don't even want to know how much these things cost. I get a big enough headache knowing how much my bills are.
Howard: Last question because we are out of time. We hit the sixty minute mark. God, that went fast. You're amazing. You're also an expert in OSHA and HIPAA compliance, what should a dentist be thinking about that?
Rick: Specifically HIPAA. OSHA has been big. Last year, OSHA handed out 274 million dollars in citations just to the general industry.
Howard: OSHA or HIPAA?
Rick: OSHA. 274 million dollars.
Howard: Just in dentistry?
Rick: Not just in dentistry, in the general industry. No construction, no maritime, just service industries. Retail, hospitals, dentist offices.
Howard: So are you still doing consulting on that?
Rick: We do. I was actually in Virginia three weeks ago doing some OSHA compliance consulting. This is kind of my big push, all these other ancillary things, and I hear all the time, you see the discussions on Dentaltown "Ah, these consultants want to do scare tactics. They just want to get our money. They want us to pay them to come in and do it." You believe that up to a certain level. The whole reason I got into OSHA and HIPAA was because I had practice management clients who got inspected and fined by OSHA and the office of civil rights.
Howard: And some lives have been ruined. I'm not going to mention any names, they've been through enough. There's been some good ol' boy oral surgeons who weren't doing something right. Next thing you know, they're on national news and they're testing all their patients for hepatitis and AIDS and all that. These are just good ol' boys who weren't dotting the I's and crossing the T's. There wasn't any malicious ignorance or anything like that, they were just doing stuff how they learned.
Rick: It just helps you sleep at night.
Howard: Who should you worry about more? OSHA or HIPAA?
Rick: Today, I'd worry about HIPAA more.
Howard: What should they be worry about? What's the low hanging fruit that they're messing up on that?
Rick: If a hacker can get into the department of defense personnel file, what makes you think they can't get into your server where every one of your patients' dates of birth, social security number, address, childrens' names, that's becoming the big thing now for identity thieves. They're hacking into small business servers and taking kids' social security numbers, who are eight, nine, ten years old. Imagine your eighteen year-old son goes to apply for his first credit card and is told "We can't give you this. You've got 150 thousand dollars worth of debt that's in default." And it all came because somebody, ten years ago, hacked into your dentist's server and stole your identity.
Howard: I can see several online courses you could be doing for Dentaltown. You think you might be up for doing that?
Howard: God, I'd take an OSHA, I'd take a HIPAA, I'd take your book. I'm your biggest fan. I really am. I'm a big fan of your posts. We are completely out of time, three minutes over time. I just want to say, seriously dude, I love your post. Thanks for spending an hour with me, you're on the road working hard, there you are in a hotel room and setting up skype. I think you are our first guest who skyped me from a hotel room. Seriously, thanks for all that you do for dentistry, thank you for all that you do for Dentaltown. I just had a rockin' good time with you today.
Rick: Me too. Thank you very much. Thank you.
Howard: All right. Have a great day. You think you'll do that audio book?
Rick: I absolutely will.
Howard: I would love that. I'm a cyclist. When you're doing a hundred mile bike ride. Guys at the end of the bike ride will sit there and say "I just listened to the whole six hour Napoleonic Wars" or "I just listened to an entire deal on some history or autobiography." It's really the rage. It's hard to sit down in a chair, being an OCD monkey, and read a book for six hours. But if you're going to go on a six hour bike ride or a hike. My son, he likes to do podcasts when he goes on a five mile run. In our day, it was music on the sunny walk, but now it's information. I'd love to have that in audio book for me. That'd be awesome.
Rick: We'll get it over to you.
Howard: All right, buddy. Have a great day.
Rick: You too. Thank you.