Put Up Or Shut Up

Doctors have long enjoyed a privileged position in American society. However, with the Internet spawning a rowdy, young generation of nouveau riche entrepreneurs and technogeeks, today’s physicians are startled to discover that their money no longer carries quite the same clout as before. In the good old days, no one dared to doubt a physician’s creditworthiness. But the times, they are a-changing.

The facility at 450 Sutter Street recently made headlines in San Francisco. Known for many years as the “Medical-Dental Building,”this structure has long hosted a bevy of physicians and dentists at extremely affordable rents. Located a block away from San Francisco’s Union Square shopping district, it is convenient to hotels, parking garages,the downtown financial district, and several key mass transit lines.

However, with the explosive growth of many Internet companies (and a critical shortage of available office space), commercial real estate has taken a shocking turn. With gentrification driven by a powerful combination of greed and opportunity, the healthcare providers at 450 Sutter face the same kind of outrageous rent hikes that many of San Francisco’s musicians and artists have recently experienced. As their leases come up for renewal, they are being confronted with skyrocketing real estate costs that might double or triple their rents.

Many fear they can no longer afford to maintain their practices at 450 Sutter. But where else can they go? While the public may attach sentimental value to having a large number of medical and dental offices in an architectural landmark noted for its beautiful Art Deco lobby, the landlord of 450 Sutter is faced with a brutal reality: If long-time tenants can’t meet the proposed rent hikes, there are plenty of potential clients with new money who will eagerly plunk down big bucks for office space. Opportunity is knocking loud and clear.

For many years, physicians have been lulled into a false sense of security by the conceit that they run a practice as opposed to a business. But business is business. And the cost of doing business is often subject to the pressures of the marketplace. If managed care was a rude shock to healthcare providers, today’s new economy has a few more surprises in store.

This brings us to a sticky little topic which has always plagued the medical transcription industry: the concept of paying people in a timely manner for the services they provide to physicians -- not only paying them what they charge, but paying them on time and according to the terms of their contract. Medical transcriptionists do not transcribe for the sake of their art. Nor can they pay their bills with an MTSO’s sob stories (“As soon as I get paid, you get paid”). If MTs are not paid on time, they have every right to start looking for a reliable source of work that will not endanger their cash flow.

Many MTSOs have a hard time demanding payment from doctors, clinics and hospitals when the MTSO is a woman who has been socialized to never challenge a doctor. As a result, the behavioral patterns of many MTSOs clearly mirror the actions of co-alcoholics. They tolerate lame excuses, blatant lies, refusals to payon time and other forms of “professional abuse” because their emotional timidity turns them into victims and doormats. Some are afraid of losing a client and never finding work again. Most refuse to understand that, by not being paid on time, their work is routinely being devalued. Far too many MTSOs are in denial over the fact that -- for every day they are not paid -- their client is merrily earning interest on the“float” in some high-yield money account. They fail to understand that, because their client has no desire to sacrifice any potential interest income, he will stall payment to the MTSO for as long as he can possibly keep his hands on the money.

MTSOs whose clients are individual doctors and/or multi-physician practices usually have enough one-on-one contact to receive payment with a minimal amount of coercion. But when dealing with a huge bureaucracy (such as a hospital chain or a large university/teaching hospital), the MTSO – like so many other vendors – is often at the mercy of some petty control freak who works in the Accounts Payable office.

Two years ago, Alert & Oriented Medical Transcription Services was approached by a prestigious clinic affiliated with one of Northern California’s largest teaching hospitals and asked if we could take over their account. The clinic’s doctors were extremely unhappy with the quality of service from the previous MTSO (whose turnaround time had deteriorated to two weeks). Although the clinic was undergoing a chaotic move to a new facility, the practice manager signed a contract and agreed to a launch date. My business partner and I were very careful about specifying our launch date because Tom had scheduled a trip to Paris and was not about to sacrifice a sorely-needed vacation.

With most clients who operate in a state of perpetual crisis management, this would have presented no problem. However, several weeks later the practice manager called in a tizzy, insisting that we start work immediately. With Tom about to depart for France, we made it crystal clear that things would be a little slow in the ramp-up phase. We promised to do the best we could, despite the fact that the client had changed the start-up date on such short notice.

Within 10 days, the clinic’s turnaround time had been reduced from two weeks to 18-36 hours. Ever since then, the physicians at this clinic have been ecstatic over the level of service they receive. On several occasions, some doctors have started their dictations by profusely thanking us for improving the level of patient care with our speedy turnaround time on transcribed reports.

There’sjust one hitch. The terms of our contract state that payment is to be “Net: 30 days.” Not 60 days. Not 90 days. And not whenever someone in Accounts Payable feels that the moon is in Sagittarius and that might be a good lunar position to favor writing a check.

Unfortunately, the Accounts Payable department at this particular hospital is a notoriously slow pay. All types of vendors (whether they provide the hospital with medical supplies, answering services, or medical transcription) are constantly tearing their hair out because they can’t get paid on a timely basis. Invoices have been known to get lost in the university’s internal mail system and there have been numerous administrative “reorganizations.” Often, when we call to inquire about payment, no one responds to our messages. Or else people say “We’re looking into it,”and never follow up.

Basically, the left hand doesn’t know what the right hand is doing. As so often happens when dealing with a major bureaucracy, vendors must endure the kind of wild goose chases that make Alice’s encounters with the Mad Hatter seem tame.

• “What do you mean you can’t pay this invoice without a purchase order number? You’ve paid every other invoice without a purchase order number!”

• “Exactly what do you mean when you say that it would be so much easier for you if this clinic could work with another transcription service whose invoices you’re used to handling?”

• “Whenever we’ve asked you for a purchase order number, you’ve said you couldn’t give us one without someone else’s approval! The clinic’s practice manager has gone through five layers of administrative approval and you’re telling us that you still can’t write the check?”

• “How are we supposed to get a purchase order number from you if you won’t give us one?”

In December, 1999, someone from this clinic sent us some gift certificates to Macy’s and profusely thanked us for the work we do. While it was a lovely gesture, we would have much preferred to receive the $5,000 that was past due for services rendered. In May, 2000, we went to the mat once again and withheld delivery of their reports until we could force the folks in Accounts Payable to pay the clinic’s bill.

In August, 2000, Alert & Oriented upgraded its digital dictation system from Digital Voice’s DOS version to its much more powerful Windows-NT version. Soon after taking delivery of our new computer from DVI, we decided to put one of the software’s lesser-known features into action.

Because so many people haven’t got a clue about the dictation/transcription process, precious few understand how intimate and private the act of dictation can be. When a physician signs on to start dictating, he is as emotionally vulnerable as someone who is about to accept an Academy Award. The last thing he wants is for the entire audience to see that his fly is open. With that thought in mind, we decided to embrace the old adage that “These are desperate times and desperate measures must be taken.”

With the help of DVI’s technicians, we were able to choreograph a chain of events so that a customized message was heard by a select group of dictating physicians. Starting on Thursday, August 31, 2000 at 12:30 p.m., any and all doctors from the clinic who dialed into our digital dictation system received the standard greeting:

“Welcome to Alert & Oriented. Please enter your ID number.”

After entering their author code, this is what they heard:

“Your account is now more than 60 days past due. You may continue to dictate. However, according to the terms of our contract, we are withholding delivery of your transcribed reports until your balance has been paid in full. Please enter your work type.”

At 2:30 p.m. on Friday I got a call from someone in Accounts Payable stating that, yes, there had been “some kind of a glitch.” Quite miraculously, all three of our past due invoices had been faxed over to her and our check would be cut on Tuesday, September 5. This woman then asked if there wasn't some way that we could turn off that ugly recording. At such moments, it helps to combine Nancy Reagan’s advice with one’s previous experience in S&M power games. I just said no.

As you can imagine, I listened to a lot of begging and whining about how totally unnecessary it was for the doctors to continue to listen to our nasty little recorded message. But I stood my ground and made it perfectly clear that our recorded message would stay in place until we received our check.

With a true sense of caring and compassion, I calmly explained to Our Lady of Accounts Payable that I had absolutely no qualms about making sure that the doctors who so highly value our service continued to”get the message” for another week. Why? Because every time they were forced to listen to that recording, it would remind them that the reason their work flow had been stymied -- and the reason why the quality of patient care at their clinic had been compromised --was because of some incompetent clerk. Or the chaos that reigned supreme in the university’s Accounts Payable department.

In certain business situations a little blackmail goes a long way toward getting results. Later that afternoon, when a confused physician called to inquire what was meant by the message that his account was past due, I politely explained that the university hadn’t been paying its bills. “I see,” he stammered. “So if I dictate reports this afternoon, when will I receive them?” My reply was short and sweet:

“You’ll receive your reports when we receive our check.”

On Wednesday, September 6, I received a call apologizing for the university’s failure (due to the Labor Day holiday) to cut our check as originally promised. However, I was assured that I would receive a phone call the following morning, telling me when our check was ready so that I could pick it up. “We have the money,” stressed the woman from Accounts Payable.

And so, exactly one week after we went live with our message to the clinic’s doctors, our little hostage situation was resolved. Alert & Oriented finally deposited the university’s check. Within 24 hours we released the physicians’ transcribed documents to the clinic.

The moral of this story is a very simple one: All of the stress, anger, frustration, ill will and bureaucratic nonsense that transpired could easily have been avoided -- if our client had only paid its bills on time!