Hello ladies

I am starting as a new solo hospitalist. Can someone please help me with the first steps of the billing process. Out of residency for several years, and this is the first time I am working on my own and billing. At this point, I can't afford a computer medical billing software, or billing consultant's fee, especially when I have a lot of time seeing only a few patients in the beginning.

If anyone can help me with even where to start, I'd greatly appreciate it!!!

1) Has anyone (a hospitalist) who sees 8-10 patients a day successfully billed by doing it herself? Without software at first?

2) The patient has BCBS. I am not on the panel. So there is been no contract. I saw the patient on an emergent/urgent basis at the hospital, as pt's usual PCP was out of town. I think I can bill for this--am I wrong?

3) So what do I do next? This may be the stupidest question: but do I literally just write a letter to the insurance company with a bill? I am really afraid of taking the first step because I've heard all those horror stories...

4) How should I set my fee schedule? Is 150% of medicare fee schdule unreasonable? (I do have an UPIN and PIN with Medicare).

Of course I can just pick up the phone and call in BC/BS, but I am afraid of sounding totally clueless and be taken to the cleaners--so I am hoping going in with at least some background information. Hopefully someone can give me some guidance. Thank you so much.

I am not a hospitalist, but I have done my own billing, without commercial software. I don't know the answer to all of your specific questions -- maybe someone else does -- but I will just mention a few things.

It is great that you are learning about billing -- even if you use a billing service in the future, at least you will know how to make sure your biller is doing a good job. I took a medical billing course at a local community college -- I think it was two weekends -- and that taught me a lot. I ordered the claim forms from AMA Press, along with coding books. Keep in mind that I did my billing before the new HIPAA rules came into effect and before electronic billing was so ubiquitous, so things may have changed.

As for your BCBS case, you can always bill for your work. The question is how much the insurance company will pay, and how much the patient will have to pay. Either calling BCBS or sending them a letter along with the claim form will work. The people you contact in customer service are usually very helpful and I learned a lot from talking to them.

Are you sure that billing services are too expensive? The ones I know about charged about 6-7% of the fees received. As you get busier, billing will take up a *huge* amount of your time and you will probably want to transition to using a biller.

As for the fees you can charge, can you believe that it is considered illegal for doctors to ask each other how much they charge? It is crazy. You have to go through a third party (like your professional organization) to find out how much other doctors bill. How can doctors possibly be guilty of price fixing when we all know that it's the insurance companies who control how much we make?

Good luck!

Dear sahmd

Thanks SOOO much for the advice and the encouragement. You have no idea what these tips have given me in terms of motivation and hope. I hope one day I'll be able to pass on the knowledge...

Even for something so simple as "do I just write a letter to the insurance company?" I have found that most MDs of my peers have no idea. None of us was taught basic E&M coding and billing in residency. And in practice, I know just as little. That is because most of the doctors that I know of are working for someone else. And regardless, everyone seems to outsource out their billing to a third party. This in my opinion is supporting a "parasite" industry that takes money out of our health care system, and takes the paycheck out of the MDs wallet. It also makes us dependent on other people where our own income is concerned. I saw an ad on the internet that is teaching lay people how to bill, and at the end, there is a big sign that said "THERE IS A LOT OF MONEY TO BE MADE IN THIS BUSINESS."

I know for a fact that there are a few physicians who have been able to make a sustainable living being their own boss, and learning about billing and coding. I really admire these people for their entreprenueurial spirit. Please forgive me if I sound harsh when it comes to the billing/practice consulting industry, and dealing with third party providers.

Currently I am entirely broke--having broken off with a group and now being on my own I need to save as much money as possible. It has been so easy to rack up a credit card bill, even with a small operation as an one woman hospitalist practice: lawyers fee for incorporation, malpractice, fax machine, phone lines, beeper, business cards, hospital privilige fees, license fees, etc. I don't yet have the resources to take billing classes--they range from $200-$1000. Neither do I have money to pay for a "practice management" consultant who is charging me $500, plus $250 for Medisoft, the software program.

So in the meantime I will do my home-grown gorilla method and try to do this with patience, force and persistence. Tomorrow I am going to the hospital billing department to see if I could ask for some more tips. I will buy the AMA books as you recommended. I don't have too many patients anyway in the beginning so I am ready and willing to go head on with the insurance companies. I will try to update my journey on MOMMD, and share information with others who may find it helpful. I do feel that as physicians, female or otherwise, we need to get to the root of the money, as that is where the power lies. My hope is that if I could get through med school, residency, and MCAT, I should be able to go mano-a-mano with the insurance beast. It is frankly a scary, but somewhat exhilirating journey to visualize my first check from BCBS or Medicare, made to me directly!

A quick and cheap resource for E&M coding is statcoder. It's a PDA program that allows you to tap in what you do in the way of hx, px, and decision-making and it will automatically give you the correct level of service. Since people have a strong tendency to undercode if they "guess" what the code should be, it will keep you from short-changing yourself. www.statcoder.com
You can download a trial copy and see how you like it. It will also help you figure out what you are missing in your documentation to get higher level codes. For instance, anytime you admit someone with any life-threatening illness, anyone who gets IV narcotics, anyone with an abrupt mental status change, or anyone with a severe exacerbation of a chronic illness (COPD and DM are the real common ones for this), it is high-level decision-making, but if you don't document 9 systems, 18 bullets in your physical exam, you can't code it at 99223, and actually just missing one bullet in one system will drop your code from a 223 to a 221. Download statcoder and try it out. I have been amazed at the number of times my residents admit a suicidal OD to the ICU on a vent and don't document 9 systems, 18 bullets. Good luck to you.

Good for you, alternativeMD!!! It is true that doctors are really in a bind when they are dependent on others for their income. Despite the benefits, here are some problems I or people I know have had with outsourcing the billing:

- embezzlement by the billing company
- billing company going bankrupt suddenly, leaving doctors to scramble to meet billing deadlines
- billing company doing sloppy work
- billing company writing off insurance-company denials because appealing them is too much work
- billing company writing harsh comments to patients in doctor's name
- billing company not noticing that Medicare had not paid the doctor after 6 months of seeing lots of Medicare patients

So you can avoid all these problems by learning about it and doing it yourself. And if and when you choose to hire someone to do your billing in the future, you will be able to supervise them so much more effectively.

Good luck with your project, and I hope you get your first check soon! If you have any questions that you think I can answer, please feel free to PM me.

Hi AnnaM
Wonderful resource, a pda coder! I'm going to try it! Yea, the 18 elements always kill my billing too.
To share 2 amazing websites with everyone what I have on my Palm:
www.fpnotebook.com (comprehensive quick reference on every disease you will see in internal medicine)
UCSF Dept Medicine Hospital Medicine manual
http://medicine.ucsf.edu/housestaff/handbook/index.html (recipes and golden nuggets for hospital medicine)

Sahmd
Wow, I can theoretically imagine all those possible scenarios but have never heard it stated with such excellent explicit analysis.
It's no wonder that when I ask around for recommendations for billing companies, NONE of my colleagues has been able to unequivicolly recommend their billing company.

I'll take away what you have given me so far, and go along with it as far as I can until I am at the next roadblock at which time I will ask for advice. Thanks again, especially for the offer for PM. Simultaneously I will try to keep this forum public so this way the community can benefit from my mistakes!

Just a little update on my "entreprenuerial" journey.

I went to school and residency and learned how to be a doctor. Now I am in a whole territory of how to collect money for being a doctor. Oh, boy, am I in for a surprise.

By the way, for those of you who watch Oprah and fantasize about an "entreprenurial" life. all the glory and benefits, well, think before you jump. The downside of being your own boss is that it often requires you to do things that you are afraid to do, things that nobody wants to do, things that are so unnatural for you, or things that are repulsive to you. This is why I believe the adage more than ever: if you are going into business, do something that you feel passionate about. The passion and love will alone will be enough carry you through these difficult times. The money, the prestige, the security, even love and support from friends and families may not be enough to carry you though.

I was not looking forward to the business aspect of medicine, and was procrastinating like crazy. Out of fear. I waited for days and weeks even. But at the suggestion of SAHMD, I finally took some basics steps. Last week I mailed out my first hand-written, paper, homemade claims to BCBS! Woohoo!!! I even made a little "shrine" of it before I let it into the mailbox, because I was so very proud of what it represented.

You may think, gee, that seems like a small thing. But for me it was like climbing the Himalaya--or at least onto the next station on it.

Let me tell you why. Because I am not comfortable talking about money, and on some level, I am a worrier. Sending this claim out, prior, I had all kinds of negative thoughts. All the what ifs.

(By the way, as far as I am concerned, going to medical school and residency was a piece of cake comparing to the business of medicine. In those structured lives, you know what you will get at the end of it. Very simple. But in business, you never really have the gurantee of success. Also, in business, everyone else is looking out for their best interest and sometimes they will cheat and screw with you. And you must accept that in order not to be driven crazy and ruin the rest of your life.)

My worries were:
What if I don't get paid?
What if the insurance company took advantage of me?
What if the insurance played dirty tricks with me?
What if the patient got pissed off that she has to pay so much out of pocket?
What if the insurance company forced me to sign on as a network provider?
What if I had to call the patient up and talk about money???? This last aspect scared me the most!

This patient was not the best candidate for that virgin call either! I dreaded, dreaded at the thought of calling her asking for money. Just think, imagining calling one of your more challenging and needy patient for money?

It scared me a lot.

Sure I can outsource out all of this to a coder, a billing company, a clearinghouse, a collection agency, a practice management consultant. All these people are in the business of doing exactly what I dread doing. I could have bought computer software to fill out the claims. But that's 6 people right there! You've got to pay all these people! First of all, being a slow startup at this time, I don't even have enough money to pay for food. So I can't afford it. Secondly, one of my fundamental beliefs is whoever controls the purse string of money, controls the show. And, the more people who go between you and the patient, the less money you can make. All your overheads will demand that you have to be more "productive."

I could have just joined a group, go to work, come home, and get a paycheck. I have been asked by many groups to join them. But when I was working for other people, I was frustrated by the setup of the practice. I was told how fast to see patients. I was driven nuts by the inefficiency of our office management. Money was an elusive object for me. I never knew how much revenue I had generated, and how much overhead was...or how much, possibly, my employer was making off my sweat and tears! I had no idea of my revenue because I didn't even know what billing was about. Believe me, money control the way one practices medicine! So in my heart, I know that in order to be the kind of doctor that I wanted to be, I have to first be a business person that allows me to practice like that.

So I struck out and became a solo, independent hospitalist. I saw my first patient, and now I had to bill for encounter, the total of which came out to be about $1600. A nice chunk of change for seeing 1 patient over the course of 6 days!

I went to the library and looked at the CPT code book and read the section on E&M. Looking at the ACP website I found a little cheat sheet on the CPT codes. I also found a really great article somewhere on the net, I think it was AAFP, about E&M codes explained in layman's language. It took me about 2 days in total to really understand the concept of E&M coding and documentation to support the CPT codes.

Then very fortuitously I found in the library, right there on the shelf, next to the CPT book, a book published by an independent company on FEE SCHEDULE across the USA, with geographic adjustment coefficient.

This neat book gave the 25th, 50th, and 75th percentile of fees charged by doctors on each CPT code. And it had a little section on HOW TO SET A FEE SCHEDULE.

So I set a fee schedule. Imagine that, little me!

I set it at 50th percentile adjusted for my geographic location. My GAF is 1.061 which is something I memorized without effort because I used it so often in coming up with the fee schedule.

Next, I learned about ICD-9 codes. I found out that as of Oct 2005 we are already using Oct 2006 ICD codes. So I went back to the medical library and asked them to buy the new edition, which turned out to be already available in the backroom, unopened.

This is when I got lucky. I knew I needed to find more help. So wondering around the hospital, I chanced upon the billing department. Then I walked down the corridor not sure of what will happen. So fortuitously I saw a plaque on someone's door: Mr Collins, Senior physician billing specialist, certified coder. Bingo. That's the right person!!! My heart skipped a beat when I saw that with joy.
So I went in and introduced myself. What a nice man. I was so nervous at first that my mouth was a little dry because I knew I had to be diplomatic in explaining why I am doing all these unconventional things for myself and why I was asking him for free help. But somehow I came across explaining my dilemma, and he was ready to help. I showed him the forms, and the basics of how I proposed to do my billing.

And across the desk, he immediately spotted the CPT codes that I had scribbled down, and without blinking an eye, he said, "wow, you spent a lot of time with that patient." Gee. That's when I knew that this man really knows what he is talking about! From across the room, when he saw my doodled CPT codes, he immediately knew what they were! He must have the entire CPT codes memorized in his 14 years of experience in billing! I couldn't believe my luck. He anwswered all my questions. He showed me how he uses the ICD9 book, how you have to look at both the front and the back to get the most specific level of diagnosis. We then chatted about his observations and career in billing, and I listened to some of his woes and victories about being a professional biller. I was in there for an hour and half without him charging me a dime! I am thinking of sending him a little present for Christmas. I am truly grateful.

With this unbelievable luck I was feeling more encouraged than ever, feeling like I now have the tools to proceed. I also reminded myself something that SAHMD had adviced me that was extremely helpful, which was that in her experience most people on the other side of the insurance company are very nice. These events allayed my fears. So maybe I won't be screwed after all...

Next I went to the Medicare website and downloaded a CMS 1500, HCFA form for free. I have an excellent printer-fax-copier at home made by HP Officejet 7310. The free downloaded version seemed legit. I just couldn't figure out a puzzle though: if these forms were ready for download for free, why are there companies that sell these forms? Are their forms better? Something else didn't make sense. The companies sell these forms in various flavors: punch out, with or without barcode, single or double, red vs black-and-white????? Which is the right form me to use anyway?

Trying to save money as much as possible, I downloaded the FREE form from the CMS website. It looked great.

I went through about 5 forms (all for free), first written in pencil, before I finally filled it out as correctly as I knew how.

I made a copy of the patient's medical record of admission data as generated by the hospital, and basically filled out the information on the CMS form based on the hospital admission record. Of course I looked at the BCBS website to see if there are any specific information that needs to be filled out according to BCBS gudielines. I also looked at the CMS website for general information about how to fill out the HCFA paperwork. I am sure there are lots of deficiency as it stands.

Next, I looked at the ICD 9 codes and verified it with what the hospital biller had written in the "attestation" page of the hospital record. That is when I realized that the doctor is the best person to code. Because even though I had written pulmonary edema, post op, in various forms in the record, the biller had not picked it up. It is not the biller's fault. The biller is not a physician. How is she suppose to understand the medical record like the way the doctor would? The sentinel reason that this patient stayed so long in the hospital post op, was because she had de-sat episodes in the middle of the night, which I contributed to pulmonary edema, as confirmed by BNP measurement, improvement with diruetics, and lack of alternative explanation like a PE based on negative dopplers and CT. This fact alone could have bumped up the hospital DRG code. A little mistake here, a little mistake there, how much are the doctors and hospitals losing money, I wondered. Though I thought I had documented it correctly, the hospital professional coder had entirely missed it. Wow, a newbie like me, already knew a little about coding that the professional coder missed. That's called Working Knowledge.

But I am sure I will hear back from the insurance company soon as they laugh their heads off on how inadequate my claim form is. Nevertheless I am determined to get to the bottom of this claim.

alternativeMD,

Congratulations!!! That was a real milestone! And you have done a great job of explaining just how complicated doing your own billing can be! And how much MORE complicated it must be for people with no real medical background (i.e., billers).

So what was the title of that book that listed all the percentiles of fee schedules? That sounds like a great resource.

Just to clarify for people (I know you know this already), the CMS-1500 is officially printed with red ink, and as far as I can tell, you can't get these for free anywhere (unless you sign up for a free trial of billing software or something). The free one is black and white. Some insurance companies will accept the black and white one, and some won't (I don't think Medicare will accept it -- isn't it bizarre that their web site offers it, though?). The red ones work better with the larger companies' scanning software. So in the long run, it is probably simpler just to buy some red ones (they're not too expensive). Choose the kind that will work best with your typewriter or computer (or pen!). I just used the plain single sheets. I think they had bar codes (I packed these things away so I am relying on memory), but I was using my computer to fill them in, so it might be different for you, since you are doing them by hand.

As for dealing with patients, the great thing about doing your own billing is that you have the option of being nice to patients! You don't have to send them to collections if you don't want to! If they are having trouble paying, you can come up with an installment plan ($25 a month) or give them a discount (charge what an in-plan co-pay would have been) or even write their portion off. Medicare has pretty strict rules about when you can write off a patient's debt (a certain # of calls and letters to the patient), but I don't think other insurers really know or care. If you document your interactions with the patient, you should be okay. Also, I would always exhaust all my options with the insurance company before ever sending a bill to the patient. It sounds like this woman was very sick, so maybe she will be so grateful to you for helping her that she will be happy to work with you on getting the bill paid somehow.

The other thing I wanted to mention is that another way the hospital billing department can be helpful is if a patient's insurance information is incorrect. If you get a denial saying that the patient is not a member of this plan, ask the hospital -- they have probably already figured out what the patient's real insurance is.

Good luck with your claim! I hope you get paid soon!

I have my own family practice now and the billing/accounting is the hardest part. I've decided to outsource my billing to an outside billing company for the first year as I start to get a better clue of what is going on. Then I may bring it back in house later. The company charges about 6.5% to do my billing, but there is nothing up front at all. They only get paid if I get paid. Don't ever feel emabarrassed to call the insurance companies and ask "dumb" questions. I have already asked them every dumb question possible, so they are used to it. Also, they make the process as complicated as possible in hopes you will give up and forget on collecting. Be persistent!

Dear Button,

It's so wonderful to hear that you have your own FP practice now. I have read some of your other posts, and I am so happy for you. Most of us can't fathom doing anything quite as complex as what you are and would love to hear more about everything! Please keep us posted!

Thanks to SAHMD again with the invaluable advice that you have provided, things that I did not know before. I still haven't heard back from BCBS yet. From reading your post, I will probably need to get the red-optical scanning type of HCFA form once I get that "REJECT" letter...

SAHMD's advice about going to the hospital billing department to find out patient's insurance status is priceless. I will use that, a keeper.

The neat little book that I wrote about last time is called Medical Fees in the United States:
Nationwide Charges for Medicine, Surgery, Laboratory, Radiology and Allied Health Services. It is published by PMIC. The version that I chanced upon is 2005. I believe there are other books similar to this. You can find these books in a good medical library at a large hospital. Better yet, get a couple of different versions, and see how they compare.

For those of you who don't know what a HCFA (pronounced hick-va) is, here is a little summary. Basically, it is an universal insurance claims form that you fill out, to your insurance payer (whether BCBS, United HealthCare, or Medicare/Medicaid, whatever) to get paid. It doesn't matter what your specialty is, or what your insurance company is--almost always, you have to use the universal HCFA form.

So what do you do with a HCFA?

Well, when you fill out a HCFA, you are essentially saying that you did such-and-such service, and you deserve to be paid such-and- such amount. It is also called a CMS-1500 claims form (which by the way you can download for free, and you can see what it looks like, off the cms.gov website).

The reason that it is called a claims form is that on it, you are only "claiming" how much your service is worth, or even that you did the service. Number one: both aspects are open to audits so make sure you fill it out correctly.

Number two: You can only "claim" that you should be paid x dollars. Whether you actually get paid x dallrs is a different story. There are numerous reasons that you might get paid less then x dollars, which you "claimed" you deserve.

I think it is an interesting word from a language/semantic perspective, in that, as doctors, we can only "claim" that we did such and such service. When we "claim" that we deserve to be paid such and such amount, it creates the implication that the "claims" is subject to scrutiny by non-doctors. An anology: a crime is only an "allegation" until it has been fully investigated by not the person who did or did not commit the crime. It is a microcosm that shows you how finance works in the healthcare industry, i.e. doctors do the work; but their "claim" is to be granted or denied by people who DID NOT actually do the work. In other words, how much you think you should get paid is subject to review, approval, and disbursement. If it sounds complicated, it is. In a recent study, the administrative aspect of US health care (which amongst other things includes the "claims" process) accounts for 20% of the private insurance premium cost, costing us as a society millions and millions of dollars that could be used for real health care delivery--but that's another topic of conversation.

I think this is a subtle business understanding that people who are contemplating about joining this profession, must consider before they dive into this career in the 21st century of insurance-controlled medicine. Otherwise, they will face a rude awakening, and endless frustration with dealing with third party payers if they can't get over this idea. I am not saying that this is right, but just that this is the way it is. Why and how this is the way it is, well, that's again another story.

Anyway, let me not digress. My hope is to empower those of us who are already in the trenches and are dealing with the professional pressures.

So back to Hick-va. HCFA comes in black-and-white version, or a red-and-white version, the latter is optically-scannable by the insurance company computer to quickly process the form. Now a days, many insurance companies, medicare and private insurances are beginning to have the e-version of HCFA. There are medical softwares, many many of them, that deal with electronic submission of e-claims. Of course, every e-company has its own version of the same thing--just like there are 20 versions of blenders on the shelf when you go to Target's to buy a michine that chops up fruits to make a smoothie. Each blender has its whistles and bells, and price tag. I can't say that I know anything beyond that about electronic claims softwares. As far as I know, there is no "consumer report" type of analysis of side-by-side comparisons of these medical billing softwares.

So, what does hick-vas have to do with us women physicians? Well, a hickva is the first step towards getting paid. It captures how much you charge, and is the first step towards how much you are paid. How much you get paid and how much the practice gets paid, directly translate into whether we can be home at a certain hour to cook dinner, whether we can vacation break with our little ones, whether we get that extra raise to buy some extra gifts for our family, or whether we can get Thursday night off to see a movie...

I think women have been very successful in getting into medical school. But I still see women as not the ones controlling the money behind the industry, and that is both bothersome and worrisome to me. I would encourage doctors, especially those in residency or freshly out of residency, to look at a HCFA form as a starting point to see how you get paid. Whether you are in charge of the money, or not, it is to your benefit to know how money comes and goes in your work.

One word of caution. You don't want to antagonize your boss by "knowing too much," or asking about money, which can raise suspicion and threats. Also, you don't want to undermine your boss's hard work in setting up a practicce. But you can do this quietly and wisely. The bottom line is that the more you know about finances, the more you have control over your work life.

Say, you are in practice with a bunch of other doctors, and your boss is telling you that you are only worth so many dollars, hence you have to do more calls. Or that you have to do more calls because other people have been there longer. Well, if you got a hold of your billing and collecting, you can analyze financially $ how much you are worth to your practice, as it compares to "other people." Then when you have the actual $ figures, it may allow you better prepared to negotiate with your boss regarding compensation and benefits. It's hard to negotiate without the actual figures in front of you. Business people don't like to make decisions without $ figures in front of them.

Or, say, you are a geriatrics prone doctor, and you are spending a disproportinate amount of time talking to your patients. Are you documenting your visits at the very highest levels, to capture the revenue? And are you showing this $ figure to your boss so that he can see that even though you need more time with your patients and seeing fewer, you are bringing just as much income as that other guy who is seeing more frequent shorter visits?

Maybe after you looked at the private insurance fees for simple coughs, and the Medicare insurance fees for geriatric train wrecks, you decide then that no matter how cute that 90 year old lady is and how satisfying the visit is to you on a soulful level, it does not justify the level of care that you spend with your patient. I.e. that geriatrics doesn't pay, and you might not want to keep on doing it. Again, I am not saying what is right or wrong. I am not saying that you should or should not do geratrics. But these financial issues must be addressed even in residency before you pick a specialty, but these money issues are not on a systemic and honest level for our trainees. Even though your passion may be for geratrics, you realize that you'd have to pay a price for your passion, and your future family will have to pay a price for your passion...

Sometimes knowing how much you are worth can even determine how fast you have to pee in a busy practice. When I was in private practice,
our boss scheduled us from back to back. We had no time to pee! We had to take turns to go use the little boy's or little girl's room!

You can keep track of your billing for one month and come up with something to work with.

For another thing, say your practice is disorganized, and you are losing money because of the way the system is set up. Perhaps you can diplomatically and respectfully go up to your boss and make some suggestions about how to change the managment techniques to recuperate that lost income. Be careful. Again, you don't want antagonize or threaten your boss. Keep in mind that some bosses have fragile egos. But if you did this right, with great tact, the boss will become quite appreciative of your looking out for the practice...

I for one was a naive young doc who was an associate for two older docs who ran the practice. I saw hundreds of patients, but never once I looked at the billing process. I was simply told to see x number of patients given y number of hours, because if I didn't do that, I "was not worth my salary." Looing back, I wished I had learned more about billing and coding when I started out. At least I'd know whether the billers did justice to my hardwork. Or, whether my practice was in trouble because the biller didn't bill correctly. Also, I'd know whether my boss downplayed the revenue that I generated, or gave me a generous pay.

Say you are looking for a job. Suppose if you knew your productivity, and you knew your practice's fee schedule, payor mix, the geographic region adjustment factor, billing overheads, aren't you in a better position to negotiate a contract or evaluate a practice?

It all starts with the hick-va!