I’ve alluded to these stories before but I want to tell one of them again, with an up date.  These are things that you could never foresee when you plan a business.  Everyone who has never done this would argue that somehow they are too smart or talented to allow these things to happen . . . but in reality, there is nothing they can do. We we chose our office space, I picked the newest and prettiest office building on our island. I think it was a smart choice. As part of our SBA loan, we had to sign an agreement that I would not leave this space for six years, the duration of the loan. We we first moved in, and had given out our address to all important entities, we noticed we weren’t getting any mail. Now the Post Office is just up the street and I’m sitting here typing and can see the top of the building easily. But, to my horrors, the Post Office told me that they did not deliver to this building.  I spoke to the Post Master and he said they “never would and never will.”  That was the only reason given.  They had also sent back all of our mail as “no such address.” This caused a huge amount of nightmares including having our malpractice cancelled because we didn’t pay the premiums. It also caused a stir with many of our vendors, such as insurance companies. Finally we had to get a PO Box at the Post Office while we continued our fight.  We had to give a “change of address” to the PO Box. This created a month delay in getting our payments and almost caused us to go bankrupt last summer. I was about to give up the fight in December, when Regence and a couple other insurance companies announced that they would no longer do business with practices who receive their mail via PO Box.  One insurance company had already denied $3,000 in claims because of having a PO Box.  I had to move forward more aggressively. The Post Office finally agreed to deliver mail but only of the mailman didn’t have to get out of his truck.  There was only one spot where a mailbox could go. The landlords denied permission to put it there.  I had to make the empty threat to move out (empty because if we moved out we would violate our contract with SBA and I would be force to pay them $65,000 immediately). So, finally the landlord approved the site. The post master took another month to give his approval. Then we put in our “change of address” to all entities. Oddly, every single insurance company, which refused to do business with us because we used a PO Box, only had PO Boxes. They are bullies and hypocrites! So, while we remain working our asses off, suddenly our income started to dry up again.  Today, we finally had the chance to work on that. It turns out that if you do a “change of address,” in our case from a PO Box to a street address, it is counted as a “move.” So, if a practice moves, then the insurance companies denies payment until they credential you at a new site. This is so frustrating and they don’t care if this makes no sense. Any excuse to delay payments makes them richer. The last one, which had not paid us in a month, was medicare. We called them and said because we moved they would withhold all payments for 4 months. That was the last straw for me so I called my congressman this morning and we are working on fixing this. But who would have guessed that this would create such a nightmare for a small business.  

We will be approaching our anniversary date in a a few weeks and I wanted to do a series, maybe just two, posts about where we’ve been and where we are. A quick update:  The demand for our services has never been stronger.  Two of the five headache practices in the state are shutting down, so the demand should continue to grow. I’m quite confident that I could hire and support a new NP or PA in headache. The trouble would be the transition months. They would want a guaranteed salary. We would not have the funds to support them until their revenues started coming in . . . which would take about three months.  I’m still trying to get my head around that idea.  The bank has refused to help us. The revenues are steady. We are not getting rich as I have a large debt load. Much of load came from the perfect storm were we had to greatly under perform for about six weeks. It was the combination of the holidays, my office manager being out ill, snow storms and my SP being out of the country for two weeks forcing us to close our doors.  But I’m paying off the Feb debt $5,000 at a time. At this rate it will take two more months. I think we have helped a lot of people. It is so rewarding having patients come from 100 miles away on a whim (having been followed by several other clinics) and then to find relief. As a couple of patients told me last week that this is the best they’ve done in 30 and 40 years respectively.  That’s why we come to work everyday. I hate this idea of having to focus on money and worry about it. But if we don’t have the money to keep the doors open, then we can’t help the patients. In this posting I want to speak of one big lesson I’ve learned over this first year. I  may share more later. A wise PA, who had started his own practice a few years ago, told me, “Mike, figure your budget the best you can. Then double your expenses and halve your income . . . then you will have an accurate number.” That didn’t seem right to me. I honestly felt like I could do things better. Be more efficient. Hire good people, yadda, yadda, yadda. But, he was right.  I wanted to talk about why he was right. The Principle of Vendors: All companies need vendors to survive. These are the suppliers of materials and services that  you need to run a business. The way that vendor companies usually work, is that they have a sales force that pulls you in.  You have to keep in mind that the salesmen work on commission.  By selling you products and services, they are able to pay their mortgage, buy their cars, put food in their babies’ bellies and buy their little princesses the latest Justin Bieber CD.  So, they are highly motivated to make the sale. Once you have purchased their product, they disappear.  Products and services are always over sold. They never perform to the level you were told and they ALWAYS cost more than you are told. What is worse than that, is that you then decide that you will not take the disappointment sitting down. So then you go to war with your vendors to get what you had paid for. You can only fight so many wars for so long and you become completely exhausted. So when a phone company says their system can do A-Z and cost $x, what they really mean is that their phone system can do A – E and cost $x+30%. If you later want F-Z, it will cost you $x+300%.  That’s just one example of hidden cost. I will give another example. I pay $500/month for billing software. My biller doesn’t like the software. I started a dialog with several companies. It was like entering shark infested water coated in blood.  The phones rang off the hook. We finally “test drove” a system that promised to cost us $300/month.  After wasting hours on it, in the end (through bait and switch) we found out it could not do nearly what we wanted then, through hidden fees, realized it would cost us over $600/ month.  But that was a lot of wasted energy and time. Positive Note: One of the things that was keeping me awake a year ago was my fear that there would not be enough patients to support practice. By hard work (connecting with our referral base) and giving our patients a good service, we have had plenty of demand.  Patients don’t seem to care who owns the practice or who sees them, if that provider is knowledgeable and compassionate. I will be back as I have patients coming in the door and I must go. That is another issue, giving up virtually all your free time in order to keep the ship afloat.

The ice is thawing after a long winter thus far, and I don’t mean literal ice.  It is the great financial drought is starting to see some relief. We made payroll without any help from anyone on Monday and I would have said that was impossible a few weeks ago. I had $2,000 come in yesterday so now I can pay rent. Our productivity increased by 81% in February over January . . . which is almost double. But, it takes weeks to see, financially, the fruits of your labor.  Our patient base is spreading to cover an area of 100 miles by 100 miles. Word is getting out. The demand for our services is growing. I can start to fantasize about hiring more help. Yesterday we got our first mail delivery to our door after 10 months of being in business. It sounds very “third-world” but we had to fight with the post office during this whole time to see this succeed. Now our payments will be less hindered. Now, if I can start paying off some debts I would feel much better. The stress of the week has been getting a total of 4 termination letters from insurance companies since Saturday.  This is very frustrating, especially considering that we’ve paid almost $20,000 to a professional credentialing company to prevent this. I did fire the company, but then they had the insurance companies call me and tell me that the terminations were due to computer errors inside the insurance company. They just simply have no accountability. Each time I get one of those letters, I think of the 100 or so patients who would be devastated if they couldn’t see us. Speaking of letters, I got a glowing letter of support from the # 1 headache clinic in the state, the one at the University of Washington. They made it clear that we are the only high-level providers of headache medicine in our region. We can use this letter to fight with other insurance companies. But for now, all seems well on the horizon.  I awaken early this morning with the news that my son and daughter in law were in the hospital to deliver their second child.  That’s why I’ve been up since 4:30. That’s why I have time to write.