An Interview with Debbie Grisanti discussing how to run an effective Functional Diagnostic Medicine Front Office

Transcription

1 An Interview with Debbie Grisanti discussing how to run an effective Functional Diagnostic Medicine Front Office Okay, welcome everybody to lesson number 4, and this is a wonderful opportunity we have today to really look at the business of functional diagnostic medicine, the front office aspects of it and how to run a functional diagnostic medicine office. And we're very fortunate to have Debbie Grisanti with us. Welcome Debbie. Hello. How long have you been a chiropractic assistant? I started working with Ron in the office when we started practice, almost 27 years ago, have completed several chiropractic assistant programs throughout the years and I've actually taught a couple of chiropractic assistant programs at our Greenville Technical College. And you've actually gone through the program six times? Yes. That's great. Many people say it's difficult to work with your spouse, so what's been your secret? It's really not a hard thing to do when you have a spouse that is passionate about helping other people and it's genuine, because that is very contagious and it's fun to work in that environment. It was a little hard in the beginning just figuring out how we were going to work together, but we did work on that very hard to make it as smooth as possible. And the main key that I found out through this many years is to basically know what you expect of each other in the office to reach your common goal, which is taking care of the patient and to continue to have a constant respect for each other in the way that you're treated. Ron is really a great doctor and he genuinely is concerned for his patients, and we know that we both have to do our part to fulfill that need of taking care of them. And one thing that helped us out more than anything was many years ago we worked with a system, a company called Gerber Sequoia Education Systems, Inc Page 1 of 22

2 Corporation, which helped us set up a system for everything we do, everything, from A to Z and that helped us streamline our everyday procedures. Knowing what's expected of you and with your staff will eliminate a tremendous amount of stress. We also spent thousands of dollars on practice consultants, like I could name a few, Markson Management, Anderson Management, Dr. Fernandez, PMA, Whitehall Management with Greg Stanley. They were all really good and we just took the best from each one of those and molded it into a system that worked best in our office. Oh, that's great. How do you communicate in your office to increase the efficiency? In the beginning we started out with just memos, before the computers. We found a lot of problems with the staff and between doc and I with, you know, you told me this, no you didn't, yes you did, and I told you to do this for this patient, no you didn't. And it just wasn't streamlined. We've found several things that we've incorporated that help us now. Number one is instant message. Ron has a computer in his office and I have one in mine and my other staff has one. We each have an instant message account on there, and we can instant message each other back and forth for the little things throughout the day that we need. And you can reference that throughout the day because it stays on there, you can go back to it. And each morning, Ron gives me a list of things he would like to see done for each patient who needs to be called and so forth, that he would like to have done. He s that to me in the morning. At the end of the day, I actually answer it back to him and then the next day he sends me another one. And it just keeps us organized and it's really great for us because it's a lot of details to keep up with. I keep a memo pad that keeps a copy for immediate calls when someone comes that needs to be taken care of that day instead of waiting until the next day and that's also a good reference because you have a copy there all the time. When we get to the office we get here an hour early every morning. It's very hard to believe that some offices don't do Sequoia Education Systems, Inc Page 2 of 22

3 that because I don't know how they get by the day. It just helps to get rid of some of the surprises that happen throughout the day. You pull the list of patients, you go through it, what you're going to do for each one, and it's much more organized and you seem more professional when the patients come in because you're not running around trying to figure out what you're going to do next. And about, gosh, what was it, probably about eight years ago that Ron started getting really into functional medicine, and - so how was that transition for you? You'd been running a primarily neuromuscular practice for many, many years, suddenly Ron comes back and says I want to start doing nutrition, I want to start doing functional diagnostic medicine, I want to start doing some different labs and things. How was that transition for you moving from a predominantly neuromuscular practice to a functional diagnostic medicine practice? In the beginning, it was not smooth. I had no clue where I was going or what direction to start with because I had no help or no one to guide me, which is why I'm really excited about answering some of these questions to relieve some poor front desk girl from trying to figure it out. Basically, like I said, we knew systems worked, so I had to set up a system immediately. I figured out everything I had to do and I put it in order and I made a system for each one. Proper scheduling for this is the most vital part. We schedule all of our treatment, chiropractic neuromuscular visits on Mondays, Wednesdays and Fridays in our office. Nutritional, functional medicine appointments are done on Tuesdays and Thursdays. Each doctor will need to let the front desk person know what he needs - how much time he needs and figure out the time of the week that they want to set aside for this, but you do need to allot a time where this is just what you do and nothing else. So, Debbie, I just want to ask you a quick question here, so again, getting it clear, neuromuscular patients are seen Monday, Wednesday, Friday, and functional diagnostic medicine patients are see on Tuesdays and Thursdays, right? That's correct. Sequoia Education Systems, Inc Page 3 of 22

4 So you don't cross. So you don't have - on Mondays you don't have, you know, a chiropractic appointment and then a functional diagnostic medicine appointment, and I thin that's really clear to make that point. Yes. Okay. So what happens if you have a patient, because obviously Ron's going have patients that are - have been seeing him for neuromuscular work. What happens if they come to see him for both chiropractic and functional medicine? I actually get this question a lot from doctors calling up, and I get this question most from the front desk person more so than the doctor. It happens a lot, so basically you must have a system down. If you don't you will fall behind schedule. This take teamwork from both the CA, the front desk person and the doctor. If a patient asks the doctor about nutrition, functional medicine or anything that the doctor knows takes extra time, the doctor must - I emphasize the doctor, he basically has to have a memorized script in his or her head so that he will be able to say it without thinking about it, otherwise it's too easy to just get involved and answer the question. Mm hmm. For example, if Mrs. Jones says - "Well, you know, I've been thinking about taking some vitamins for this or that." I would suggest he say something like Mrs. Jones, that is a very important question, very important. You should schedule a time with Debbie when you leave today for me to go over that with you at a special time so that we can take our time, answer your questions. Just basically make the patient know that you don't want to rush through this, that it is important. And you can - and if the patient says something like, "You know, I really have this problem and I'd like to know if you can help me with it." I know that Ron has his staple thing he tells them, that he tells them that he would like to get a copy of their medical records and review it and he has a questionnaire he'd like them to fill out. And once he gets that then he can evaluate it, study it, and go over what he recommends for them. And they actually love the fact that Sequoia Education Systems, Inc Page 4 of 22

5 somebody will actually get all their records and look through all of them and take the time. I get no complaints on that at all. Yeah, I think the point being is that you really want to make the patient know that you care and that you're not just pushing them off onto another appointment. So saying something like, you know, Mrs. Jones, that's a really, really important question, I want to spend the correct amount of time that that type of question deserves. I cannot do it on a chiropractic appointment. So I want you to come and see Debbie, schedule some time during my workweek where we can really get to that. And obviously, you know, then he's introducing the whole medical records thing, and it's giving the patient a sense that he really cares, he really wants to get to the bottom of their case. So that's wonderful. And then the doctor can get right back focused on what they initially came in for, and he can choose to walk them up front on those occasions and only on those occasions. Right. I don't like it when he comes up front because people catch him and he gets behind schedule. But if he does that actually emphasizes the importance that this is something important because he doesn't normally walk them up front. That's a really, really good tip that applies to any practitioner. There are two golden rules that I was taught, one was never talk to your patients about money and the other one was never come up to the front desk unless you're just walking up to pick up a chart and then you can leave because patients will trap you there. And I know if you're running a neuromuscular practice, that you know, you're seeing maybe 30, 35 patients, 40 patients a day, and just even five minutes trapped at the front desk is gonna throw your whole schedule off so. I agree completely. Yeah. And how does the chiropractic assistant play into this? Sequoia Education Systems, Inc Page 5 of 22

6 Well, the chiropractic assistant should always be observant and be alert - alert the doctor of anything that they see may take extra time, because a lot of times that patient will say something when they walk in and sign in. Like, for instance, I have a few questions to ask the doctor today and so forth. I will actually go back and - or actually instant message Ron and tell him that Mrs. Jones has a list of questions today on - and kind of warn him and that way he'll have his mindset ready when she walks in to where he can tell her about scheduling that special appointment. Because you do have to work - it's a team effort to get the scheduling done properly, you really have to work together. Right. That's - the scheduling the Tuesday and Thursday appointments. Right. And if it's just a really quick question about something very basic, a lot of times Ron will actually have me get the patient's if we don't have it, and he'll just them a quick answer and he'll tell them that he's going do that later in the day. Okay. And that works well too and saves time. So let's say Mrs. Jones - let's go back a little bit. Mrs. Jones comes to Ron, she's seeing him for lower back pain. And then she mentions that, you know, her blood pressure is a little high. And Ron says something like Mrs. Jones, I really want to do - I could do an in depth evaluation of your condition, but I need to see your medical records and I'd like for you to speak with Debbie, and she can explain how that works. So she now comes up to the front desk. She's saying, "Dr. Grisanti has asked me to talk to you about scheduling an appointment where we can talk about my high blood pressure." So what's your procedure from that point with the, you know, almost transitioning Mrs. Jones - not necessarily transitioning but moving her from being just an exclusive chiropractic patient to now potentially being a patient for he functional diagnostic medicine shift. Sequoia Education Systems, Inc Page 6 of 22

7 Well, basically, I can't help myself sometimes from kind of bragging about him a little bit about the patients he helped with that problem. Well, that always helps. I just can't help it because he has and it's exciting, it really is to see these patients get better. I can't emphasize it enough. It really, really is exciting to see people get better and the looks on their face, and - it's just a wonderful thing. But I start out by saying that first, and acknowledging that. And then I tell them that for him to help them the best and to save them time, we'll need to get the most information possible. We have a questionnaire I need to give them, and then I also have them sign a medical release form and get a list of the doctors that they've been to. And I just tell them, basically, I'm going to get all their information and once we get the questionnaire filled out and all the medical records back in the office then I will schedule a special time and reserve an hour to go over all the findings, and they will get a written report at that time and a recommendation of what to do next. And that works all good and well when they're in the office and you know what they're doing, it's also important when you get a phone call for a new patient. And the new patient calling on the phone saying they need to make an appointment with the doctor, the front desk person should already be very skilled at taking new patient phone calls, but if they're not it's even more important because you need to get their name, the telephone number, find out who referred the patient, and the next thing is, what type of problem are you having or what is the main concern that you want to see the doctor for, however you want to phrase it. And then from that answer you can tell whether they need to go in the functional medicine appointment or if they are to be scheduled for a chiropractic appointment. Mm hmm. Because if it's a regular chiropractic patient, you would then ask them how long have you had the problem, schedule the appointment, confirm the time and so forth with the patient. If it's functional medicine then you have to figure out how to Sequoia Education Systems, Inc Page 7 of 22

8 get them the questionnaire, you can it to them, print it out, or you can send it in the mail, they can pick it up, and you need the medical release signed with the list of doctors to get them from so that you can get started on that immediately. And if it's a chiropractic patient, I always tell them, I have Monday or Wednesday, which do you prefer, 10 or 2, which do you prefer. I know I'm throwing that in, but that's been a lifesaver. Patients love having a choice. Yeah, rather than being forced to come in. So even if you're talking about morning or afternoon, 10 or 2, they like that. Mm hmm. And then obviously you need to tell them where the office is and all that kind of stuff, especially if they're a new patient, I guess. Right. Where are you located and I always keep a new patient pad right next to my telephone for a brand new CA I have in the office. I've done it so long that I don't keep one, I probably should, but I just know it by heart. But so if you have down everything you want to find out about the patient and you can just rip the pad off when you finish to make sure you don't forget to give them the information, it's very helpful. So you have, right by the phone you have like a preprinted pad with, you know, like basically new patient info. Exactly. And then you're collecting that information as the patient is on the phone. Now is that for chiropractic or for functional medicine or both? It's for both, and with chiropractic I actually get their s too, because we offer a service where I can them the new patient forms and they can fill it out online. Wow. I tell them how much time that'll save them and they really like that. Sequoia Education Systems, Inc Page 8 of 22

9 And do you have that facility for the questionnaire as well? Yes, I can send the questionnaire online for them to print out, and I can also them the medical release form for them to fill out and fax that to me with their list of doctors. Now, I'm gonna throw a question in here, your questionnaire is about 46 pages is that correct? Yeah, it's 41 pages. He's working on shortening that right now! Yes, Ron and I are working on that now. In fact, in tomorrow's lesson, I'll be going through the new shortened version. I like the long questionnaire though, you know why, doctor, because if a patient fills that out you know they're serious and it just really saves you time from people that really aren't that serious. Yeah, what we call tire kickers. Yeah. So if somebody fills that thing out, and I know this is one of the things that Ron has talked about, if a patient fills that out within 24 hours and brings it back you know they're a very, very serious patient. If on the next chiropractic visit Ron says, oh by the way did you get that questionnaire, they go, oh yeah, it's still sitting on my front desk, then you know that they're probably not that serious. But do you ever have patients that come up and start complaining about the length of it? Actually I don't - and I think the doctor worries about that more than the patient, because most patients like telling about themselves. And they like having a doctor that cares enough to ask them all those questions. It's not usually ever a problem. So if you're listening to this, I want you to take note of what she just said because as physicians, we worry about patients filling out long, long questionnaires and we go, goodness me, you know, it's gonna take them hours, they're not gonna want to do it, but experience says that a patient wants to tell their story to you, especially if they've been suffering a long time, and just the sheer fact that you have a 46-page questionnaire that you're giving to the patient really shows to them that you want to gather as much information. Sequoia Education Systems, Inc Page 9 of 22

10 We're talking here about being the medical detective that Ron and I have been talking about. So gathering that information is really important, and in tomorrow's lesson I'm gonna go through that and you'll get to see that quite clearly. So what are some of the office procedures you use to keep up with all this, because it's - you know, you're juggling two different things here and I'm curious about the office procedures you're using. The secret is to have a system that works for you, your personality, how you organize things. The things that I've come up with are basically - well, you have to have a system, period. If you don't you'll be lost and you can't afford to miss anything. So what I've used, number one is I have a new patient script pad I told you about next to the telephone to get all the information. That way I know I'm scheduling them for the right thing. Right. And I do have that online service that we can offer to send the patient the information online. And if they send that back it has their insurance information, I can have everything verified before they come in, it's really nice. The second thing is I do keep a telephone log, it's just a spiral notebook right next to the phone, and I log all incoming calls. This is invaluable to me to reference back to and in most states it's also considered legal proof. I've learned this in a lot of the CA programs I went through. Ah, interesting. And for the medical records, the way I keep up with those is that we have a three-ring binder and we have a form in there that has the patient's name, the doctor or facility we're getting the information from, the date we faxed it over. And then when it comes in we log when it was received and write any comments next to it. And that's very helpful to keep up with that, and that is checked at a specific time once a week mandatory by the lady that works for me, her name's Teresa, and she checks it to see anything that's past due, we make calls and notes on it that we've had to send twice. We record that. I also have an A to Z acordian file that I keep the release forms in. When the records come in, I take the form out and file it away. Sequoia Education Systems, Inc Page 10 of 22

11 Once all the records are in and the questionnaire is in, Teresa gives me the file for me to schedule the patient. And that's how you keep up with it. I do keep a functional medicine three-ring binder with A to Z tabs to keep it alphabetical. So when a patient comes in to pick up the test kit there is a requisition form, which is like an order form, that you fill out. I make copies and put it in there, and when the test results come in I notate that they've come in so that when all the test results are in on that patient, I know and I can tell Dr. Grisanti and we can schedule the report to deliver all the test results. That keeps the doctor from having to keep up with all the tests are in or not, and that's very helpful for him. Great. So how do you schedule - you mentioned chiropractic and neuromuscular work Monday, Wednesday, Friday and functional diagnostic medicine on Tuesdays and Thursdays but how do you actually go about scheduling that appointment for the functional diagnostic medicine patients? Well, first of all we reserve one hour for their first appointment. They've filled out the questionnaire; we've got all the medical records. He's reviewed it. Doc has written up a report that he's gonna go over with them. And that's their first appointment, and I do reserve an hour for that. Usually I reserve a little more than an hour because sometimes he goes over. And the second appointment is when all the test results have come in and we're scheduling a time for the patient to come in and go over what he's found out and what he's recommended. And at that time he's gotten a treatment protocol, what's he's recommended. It's all typed up and it's got what he's recommended for them to have, any tests that he's recommending. So I already have a copy of that while he's back there with them. So when they come back up front, I'll know what to do next. The follow-up appointment, they're scheduled depending on the needs of the patient. Some are in two weeks, some are in a month, just depending on the problem. And we do some in-office metabolic testing, and he'll ask me to do that, so just whatever is next. But I do tell the patient that no two patients are the same as far as recommendations. It definitely does go upon their needs. Sequoia Education Systems, Inc Page 11 of 22

12 But those are usually 30 minute appointments, the progress ones, and Dr. Grisanti does send a progress questionnaire before their follow-up appointment via for them to fill out and they send it back - the answers online. If you don't want to do that you could choose to have them fill it out when they come in, just have a few questions on like how they're doing, how they're symptoms are going, however you want to put it. But it's nice getting it ahead of time, though, it's a lot better. So Debbie, that progress questionnaire is so - Ron has reviewed them at - prior to their coming in he's reviewed their medical records, he's reviewed the questionnaire they filled out. He's got some sense of what's going on with them. He's written a short report. They come in for that hour-long appointment. At that point, he's explaining his findings, he's then making recommendations for some further testing, be it stuff that can happen within the office, the metabolic urinalysis testing and all that kind of stuff or physical exam type of things, or he's recommending some of the advanced functional medicine labs, which we'll be going over, everybody, in the weeks to come. At that point then he will send them up to you, I guess, to get the test kits. Right. I try to keep all those test kits in stock. There's quite a few. If I don't have them, I just tell the patient I'll call them when it comes in. I go over how to do those test kits, and once all the test results are in that's when we go over to the appointment where he goes over what to do. And he'll have maybe a list of supplements or diet or whatever he's gonna give them. Mm hmm. And the follow-up visits are once they've started doing whatever he's recommended and he's just following up to see how it's coming along to adjust it or you know, to make sure you're just not leaving them out there in the cold. And that's where the progress questionnaire comes in? Yeah, those are for the follow-up appointments, they've already started the treatment. Sequoia Education Systems, Inc Page 12 of 22

13 Wonderful. So how about going - you know, for those of you who are new to this you're probably hearing test kits, what on earth are test kits? Well, all of the advanced labs that we'll be using, Genova, Diagnostech, Metametrix, those types of labs that we'll be discussing throughout the course of this training, have free test kits they will send to you so you can keep them organized, Debbie said organized in your office so that your front desk can give those out. Is there anything more that you want to say about the test kits and - specifically, I guess about blood testing? Yes. Well, the test kits, just in case a person at the front desk, as I was in the very beginning, a little nervous because I've never done anything like that before, they actually all come with very easy instructions that a fifth grader could do. I mean they're really, really easy. And if you have any questions when reading over the instructions yourself, I always read over them before I go over them with a patient. You can call the actual lab and talk to tech support and they'll answer all your questions. Just be real professional and make sure you understand it before you go over it with the patient. That's one thing in every aspect of practice, never act like you don't know what you're doing in front of a patient. Right. It's just not a good thing. They're really trusting you. As far as the blood work goes, we have requisition forms, we just check off what he's recommended and we use Doctor's Choice. I highly recommend it. It gives the patient a huge discount. You work through them, the patient goes to Quest Diagnostics, which is extremely well respected lab, all the hospitals anddoctors' offices use them. It's a blood draw center where they draw the blood and send it off, and you get your results back in a couple of days and it's just really good because - working with them they're extremely professional and it's a good company to work with. I can - I have the numbers available to give that to you now or you can let me know if you want me to do that later. No, no, why don't we just give them out with the Doctor's Choice, because this is the company that we recommend that you do your blood testing, and I'm gonna talk more about Doctor's Choice in a few days. But yeah, why don't you go ahead and give the number. Sequoia Education Systems, Inc Page 13 of 22

14 Well, the number is , and it is Doctor's Choice with Dr. Kevin Bodling. Kathleen is the one that helps him there, his assistant. And like I said, they're very helpful. They go out of their way to make sure you understand what you're doing, especially in the beginning. But they'll have preprinted requisition forms to order forms that they send to you. It's very simple. We have a certain panel we use that's mandatory for each new patient that we're gonna do and those are all checked off and they go there and have the blood drawn and we get the results, it's really nice. Great. And just so you know, if you call that number and tell them that you came through from Dr. Weatherby and Dr. Grisanti's functional medicine program they will give you a discount to get started. It is a membership, so there is a membership fee to get started because of some initial paperwork and all that kind of stuff that needs to be filed, but let them know you came through from us and they'll give you a discount on that. And I cannot recommend this more highly to you. These guys are wonderful and Dr. Bodling as well. So I guess we've covered the scheduling of the appointments, so the patients come in, Ron has written the report for them, now he's recommended some lab testing. They've gone away and done the lab testing. And how about supplements, how does the supplement angle work, because Ron is gonna make recommendations and he's gonna give them a treatment protocol based upon their findings. They will then come up front to you with, you know, anywhere from two to three, maybe even four or five supplements that they will need. How do you handle that aspect? Well, number one is I am already set up with a few suppliers that I get supplements from that he feels are really high quality supplements that he likes to use, and I go over how much they'll cost and then I have them prepay for them if they are not in stock. I just ask them which card would you like to put that on. Right. I don't even say you have to pay me, I just say which card would you like to put that on, I order them and when they Sequoia Education Systems, Inc Page 14 of 22

15 come in I call for them to pick it up, and I also go over the price of the test kits and things with them too when he gets through going over that after that first visit. But this is after he's already done that and he's actually had the recommendations on there for the supplements. I have a three-ring binder that I keep the order book in, and I write down everything I order and notate when the patient's prepaid and everything. I keep really good notes and when the patient picks up the supplements I actually write in there picked up and the date. I mean I have it all organized, you just really have to organize. Mm hmm. I have several patients that ask me to keep their credit card on file so they can just call and leave me messages on the answering machine if they need to reorder supplements so it just makes it faster. Wow. So I guess if you're listening to this, one of the hallmarks of a successful practice is really having someone like Debbie who is very systems oriented, very organized, to make a system work for the office. Now you may have a system that's already working in your office but you are gonna have to transition that system to work when you're doing functional medicine and you know, really appreciate you walking through that. This leaves one very important question towards the end here, which is how do you talk about the cost? Now, you're moving a patient away from potentially an insurance-based copay visit with Ron during the neuromuscular practice. Now they're coming over to the functional medicine practice. Do you take insurance for that? I have an easy answer for that. We don't file any insurance for any type of functional medicine procedure, basically, it's because they don't cover it. If you tell this to the patient right up front then they don't have any surprises. I just give the patient a receipt for everything, each lab test does have the CPT codes where you can send it to insurance, and I give it to the patients if they want to send it in. But I just tell them that right up front. On the blood work that we do through Doctor's Choice - if they went to a lab and just paid cash it Sequoia Education Systems, Inc Page 15 of 22

16 would cost them at least five or six times more than what we charge, so it's saving a lot of money. And - but I just tell them that right up front, and we've been doing this for many years. I don't have any problem. Every now and then somebody will say well I just can't afford to do that right now but I don't get that very often. And normally they will come back like in 30 to 40 days after they've saved up the money. People will very often find a way to do what they feel they really want to do. We do offer care credit in the office, and I highly recommend that. You can sign up for that online, I believeit is carecredit.com. You can sign up to be a participating physician. Can you tell us a little bit more, I had never heard of Care Credit until Ron told me about it. Can you just give us a little bit of a description about what that service is? Well, it's like an in-house type of health credit card. They have a card, they can use it at all local participating doctors offices - there's several doctors in our area. Most of them are dentists, podiatrists, and a few chiropractors that are participating with it. And the patient just has a card and it's like a credit card and they can put their visit or the test kits or whatever on that, and then they can pay back Care Credit $30.00 or $40.00 a month. And they will pay the doctor like a credit card, they take out a small percentage just like every credit card does, and pay you and put the money in your account. Right, so you get paid upfront. We get paid upfront, yes. And so then Care Credit handles the monthly payment with the patient and not you. The doctors can do whatever they want to do, but these companies that do these test kits will not perform the test unless it's paid for. Dr. Weatherby :So that's important, the patient needs to pay for that, yeah. I think one of the important things to remember is that you're not a bank or your office is not a bank. People have the option to use credit cards and to make payment options elsewhere. So I think that's very important, make sure that you Sequoia Education Systems, Inc Page 16 of 22

17 communicate what the cost is gonna be upfront, and I love it when you say, you know, what card do you want to put that on. You don't really give them an option to even think about it. So you don't file for insurance and - do you find that people have problems with that, the fact that you charge for insurance for their chiropractic appointment, but they suddenly come up front expecting to pay a $20.00 copay and you don't accept their insurance? I have already told the patients from the second they go to fill out the questionnaire that this is not covered by insurance. I don't even let them get started before I tell them. Right. Every now and then you'll have a problem but it's not very often and as your doctor gets more and more busy and you see the actual time that's put into this with each patient, you don't feel bad about how much you're charging to do this because it's so worth it and you've got to understand where most of these people are coming from. From my experience for many years, they are worn out from going the typical medical route. They don't care - these people would go borrow money and put their house on a second mortgage if you can help them. I'm not saying, you know, taking advantage of somebody in a bad situation, I'm just trying to give you a mindset of where most of these people are coming from. And if you have a handful of enough patients that are passionate about getting better and you are getting them better, because you will, they don't care if it's covered by insurance. Right. And I'm looking here, there's a form that Ron has been working with, and we called it the Patient Acceptance Policy Form, which basically outlines the whole procedure and the process of them coming into the functional medicine and sort of explains everything, and you have the patient sign that. Yes. Okay. And it's just basically important to tell them upfront very important. Sequoia Education Systems, Inc Page 17 of 22

18 Yeah, absolutely. Yeah. On the basic bloodwork, we have had several occasions where the patient and their medical doctor are good friends, or they've been going to this one doctor for 15 years and it's not a test kit and it's just blood work that you can get done at any doctor's office, then he'll say, well, here's what I suggest they try to have them order it for them. Like they may be coming up for a physical in two weeks, and see if your doctor will run these blood test. And sometimes they will, sometimes they won't. Mm hmm. And sometimes you can do that, because you basically want the results, but it's very difficult to get a doctor to run the complete profile that we do in one visit, because they like to do a little bit at a time. Yeah, yeah. But sometimes you can get them to do it. So I guess at this point, Debbie, you know, another question to ask, we're talking about costs and how much the patients are gonna spend. Could you run through just sort of a typical cost for - you know, the initial consultation and all that type of thing? Okay. And what we do when the patient comes in to go over the recommendations where he's looked over all of their medical records and the questionnaire, he's typed them up a report and he's gonna go over what tests and all he's recommended for them to do, that's a one-hour appointment and we charge $ for that. You really have to vary that with what state you're in. Some states charge more for everything than other states do. In our state that's pretty reasonable. Mm hmm. And if a patient has one medical record and hardly any trouble and they've got a really short case and it's not very much work at all I won't charge them the full $ but most patients come in with like four inches of medical records and that's time consuming. Sequoia Education Systems, Inc Page 18 of 22

19 Yeah. I may vary that sometimes, but not very often. And as far as when they've had all their test results and he's gonna go over what to do, that's another one-hour appointment and I charge $ for that because it's for one hour and they get a report. And if they come in for follow ups after that the follow ups are usually 30 minutes and for us they're $50.00 for that. Wow, okay. But that actually may vary in some states because I know doctors in Atlanta, Georgia, it's a much bigger city, they charge more overall - basically everything is higher. So you'd have to vary that based on where you live, I believe. I think the point here is that, you know, the patients have to understand that you're not - they're not just paying for Ron's time when they see them face to face. I mean the four inches of medical records arrive, they've got a 46 page questionnaire that he has to go through. So a lot of time is spent outside of the actual appointment. We makes sure to let them know that too. Yeah, well, that's important, yeah, so it's not just, wow, I'm paying 195 bucks for, you know, just one hour of his time. It's like, well, no, he's actually spending probably for every hour - typically for every hour that you see a functional medicine patient, there's at least one to - if not two to three hours outside of that where you're reviewing the records, you're writing recommendations, you're writing reports, you're talking to lab - physicians at the labs, you know, as a query on one of the labs has come back and that type of thing. So patient has to be made aware that they're not just paying for your time, they're also paying for your time outside of the office where you're managing that case. I bring that up right upfront when I give them the questionnaire and the medical release. I tell them, because they usually always ask me how much it's gonna be and I'll just say, "We will gather all these medical records for you, Sequoia Education Systems, Inc Page 19 of 22

20 we'll get it all together. Dr. Grisanti will spend an hour or two," like you just said, "sometimes three, however long it takes to study and thoroughly study all your medical records and write you a report on what he recommends and give you your options on what can be done. And you'll get a written report and a one-hour appointment and for that it's gonna be $ " Mmm. And they're like wow. I mean really, usually they think it's going to be more. Right. In fact it really should be if you had to put a worth on it. But we try to keep it reasonable upfront so more people can get helped. And you are gonna have the follow-up visits, they are gonna more than likely order supplementation from you and so forth. But the upfront visit, if you make it too high, people may not be able to afford it. If we had to put a real price tag on it, I would charge them 5 or 6, $ And that would just make it not affordable for too many people, so therefore you wouldn't be able to help as many people. That's just my personal opinion. Well, I think that's good. Do you pass on a charge - or when somebody orders blood work, for instance, do you - typically supplements are doubled, so if a supplement cost the practitioner $10.00, they typically will charge the patient $ Are you doing that with lab tests as well? I have been told by Ron that in certain states they have different laws on that, charging the difference. You can just have the patient send the money in with the test kit to the lab and they'll get a patient price on it. It's called a prepaid price. If the doctor is billed it's usually less. You can charge the full price, retail price of the test kit and have the lab bill you, the doctor, your price but you charge the retail price and you keep the difference. It does help you make up for some of the time you've spent going over the results before you see the patient and so forth, so it's another way of getting paid for the time you put into it. But that is completely up to the doctor. I think that's a personal choice on how they want to run their office. The Sequoia Education Systems, Inc Page 20 of 22

21 patient can send the money in with the kit themselves or you can just mark on there on the requisition form bill doctor and they will have an account, like a debit card, in their possession so that when the test kit arrives to them they will charge the doctor immediately, and therefore, you have to get the patient to prepay you for it. But you can keep the profit on that to help make up for some of the time that you do spend on it. But that is a personal decision for that doctor. And I sometimes get around that by actually just passing the cost on to the patient, but when the test results come back and their next appointment when I go through the results to them, I charge lab interpretation fee. Correct, you can do that too. But, there are different laws in different states that each doctor must be aware of. As far as whether you can or cannot charge the difference on the lab tests or a lab interpretation fee. So I think that's important for everyone who listening, we've obviously got doctors in not only different states but different countries. When it comes to paying - or charging your patients for these lab tests, please check with your local laws to make sure that you are able to do that. Right. It's very fair if you do charge at least a little more because you do take the time to go over it. It's very worth it and it's a lot more fun to have patients that are functional medicine patients, they stick with you, they come back, they follow through, they stay with you like forever, because you're like their coach, you're like their health coach. Yeah, exactly. You've got their whole records you've looked over everything, you're guiding them through their life and all their health problems instead of just coming in when they are in pain. Although I highly do respect getting adjustments, I've had them my entire life practically since I was 4 years old, but it's just different and they love it and they come back and they don't miss appointments. They're like calling you, well you haven't called me back or I need my next appointment. It's just a whole different mindset. Sequoia Education Systems, Inc Page 21 of 22

22 How many patients does he typically see on a Tuesday or a Thursday? Well, - he probably could see more but he likes doing other research, so he keeps it to two or three on Tuesdays and Thursdays. But that's his choice, he could see more. He does a lot of other research and does other things, so that's what he feels like he likes to do. Great. Well, Debbie, I want to really thank you. I know you're very, very busy. You're running a very, very busy practice, and I want to thank you for taking the time today to talk to us and to really explain how you've been able to be a very active part of, not only a successful neuromuscular practice but also a very successful functional diagnostic medicine practice. Are there any other words of wisdom that you want to impart before we say goodbye? I guess it's just to wish you luck with it and to look forward to it because it may be a little extra work right upfront, but it's just amazing the feeling you get when you see so many people that have basically just lost hope and everybody in every profession has given up on them and their problems. And then they come to you and you help them, and it's just amazing the reward you get in your heart seeing these people. I can't tell you enough about that, you have to feel it and you'll love it. So it's worth a little bit of effort upfront to learn how to get this all set up. Wonderful. Well, thank you very, very much for spending time with us tonight. Okay, I enjoyed it. Sequoia Education Systems, Inc Page 22 of 22