Season 1 Episode 12 – A Conversation on Sleep Apnea and How to Deal with Trust issues in Your Team with Dr. Erin Elliott

Full Episode Transcript

With Your Host

Dr. Tarun Agarwal

T-BONE:      Hello everyone, and today we have a special guest all the way from just outside Boise Idaho, an entire five hours outside of Boise, we have Dr. Erin Elliot on.   Erin, how are you doing today?

ERIN:  I’m great. I ‘m so glad that we’ve made an inside joke about that because ever since I told you I live in Idaho, you’ve automatically thought Boise, but I’m actually ten hours.

T-BONE:      Oh sorry, ten hours. [crosstalk] Am, I’m, glad you’re closer.  I thought you’re just outside of Boise.  Now, I’ve got you at least five hours outside of Boise and it’s really ten hours outside of Boise.

ERIN:         Out here we can call that a suburb, I suppose.

T-BONE:    What else is there in Idaho? I didn’t know Idaho is ten hours big for God’s sake.

ERIN:              Long and skinny, just like me right?  [laughs]

T-BONE:      That’s what they say, that’s what they say.  So Erin, what are we going to talk about today?

ERIN:                You know what?  T-Bone, Dr Agarwal, Tarun, [crosstalk] whatever you want.  I actually would love to start out with the fact that we met virtually, never in person but online and all I knew about you is that you like to sleep.

T-BONE:      I do like to sleep.

ERIN:              In fact, there’s a whole hashtag dedicated to you.  In addition, my husband and   I have a huge [unclear] about the fact that he posts pictures of me sleeping on Facebook’s, so automatically we were kindred spirit. You and I…

T-BONE:    Yes! But I, I’ve got, I’ve got my own hash tag, you don’t yet.

ERIN:         I don’t, and I’ve never fallen asleep and got caught out of professional sports [crosstalk] game.

T-BONE:   How about I got, I got, I fall asleep parasailing.

ERIN:        Oh, you know what?  It is pretty relaxing once you get up there.

T-BONE:   Well, Listen! It’s better to sleep and not see how high up you are, especially when you’re afraid of heights like me. So…

ERIN:             Yes!  Well, At least you did it, livin’ on the edge.

T-BONE:    Well, I’d like to talk about that, three or four things today. First, and were going, I’ll list them all and then we’re going to…. I’d like to talk about Erin Elliot.  Who she is, how she got here, how you’re like everybody else and what we can learn from that?

I’d like to get sleep apnea out of the way, because certainly that’s what you built your career around and then I’d like to talk a little about being –  just your practice in general and your general dentistry part of your practice and how you’re more than just a sleep apnea person.  And then I’d like to talk a little about some courses that we’re doing together so people will get a better idea of where they can learn.

So why don’t we start with… and again I’d like to have a very relaxed conversation tone  so, if you have questions for me feel free to ask me questions, challenge me, I’ll challenge you along the way but…

Let’s start with who is Erin Elliot and give us the, give us the shortened version of that.

ERIN:         That’s a big question but I will give you the short version.  I basically, grew up in Orange County California, but I always tell my patients that I grew up south of Boise which you know, according to your geography, Southern California is the suburb of Boise. But I grew up there thinking that there was no life outside of California.

My dad was a dentist, but he practiced kind of far away from me so I didn’t grow up at around the dental practice.   And I always played soccer, excelled at school, check all the boxes and did the right things.  When it came time to finding a college, I realized that maybe I didn’t want to go to UCLA where my dad went to dental school and maybe I should explore the country.  So, I set out at seventeen years old with my mom and sister and brother and drove from Southern California to Western New York, where I went to undergrad and played soccer and went to school there.  I actually turned eighteen in Branson Missouri of all places.

T-BONE:      I’ve been to Branson [crosstalk] I actually…

ERIN:         [crosstalk – yeah, It was a wild party]

T-BONE:      Underrated town. Branson is a, [crosstalk ] It’s a fun place.

ERIN:             It was fun.  When I went to college – the whole reason well, a few reasons I choose it but one of them is that they truly believed in the student athlete, not just the athlete that you know studied underwater pottery or whatever. [crosstalk] as my dad always said. [laughs]

T-BONE:     We, at the University of North Carolina know a lot about the student athlete.

ERIN:         Yes, I bet you do. But this is a college where I actually skipped a practice a week so that I can go to my science lab and actually go to my courses and not change my major based on athletics. So it was a great balance. Loved it.  I met my husband there. I got married after my junior year and then set up to Creighton University Dental School and I loved it there because there were no specialist, therefore, we got a lot of experience.  How about you?

T-BONE:   Well, I grew up in small town North Carolina and I was more than happy to get out of North Carolina.   It’s my small town at least and go to school in Kansas City and I loved Kansas City.  I had a great time there and I wanted to move back to North Carolina to be close to my family but I couldn’t move back to a small town I was in.

So we moved to Rally and we, we’ve enjoyed it here.  My wife when we first got married, she grew up in Miami, Fort Lauderdale.  She did her best to try to get me to move but my stubbornness came in handy so I was able to by pure virtue of being very stubborn, or more stubborn than her, I was able to keep us here and I think that’s been unbelievably good decision for us.  So…

ERIN:         I can only imagine you in more humidity than Raleigh already has.

T-BONE:     Yeah, I, I hate – I swear as it is.  I hate this heat, you know, I don’t’ do well with crowds and I don’t do well with traffic, so yes, I don’t think I will do well down there.   So ….

ERIN:         Yeah, Isn’t the Midwest awesome now?

T-BONE:   It is, listen! I, I had such a [crosstalk]

ERIN:         It’s not fly over country that’s for sure.

T-BONE:     Well, that’s what it’s called; but I had such a great time in Kansas City.  I had great friends, many of whom I keep in contact with. I had a great experience in school and I thought Kansas City was a great town. We had a nice vibrant sports city, a nice vibrant you know, hang -it -out scene and it was a good place.  I would certainly consider living in Kansas City.  I think it’s underrated as well.

ERIN:             Fully agree. It’s just that when it’s came to like holy cow, I’m going to be graduating, you know, We’d looked my dad had since moved to Vancouver, Washington which is near Portland, Oregon and my husband’s family literally runs the small town in Northern New York that they’re from.

And so, we’re like where do we settle?  But North Idaho literally had everything we wanted lakes, mountains, trees, snow, without humidity and bugs.  Could you imagine a life without mosquitoes in a cool lake?

T-BONE:     I live; I live a seventy-degree lifestyle I’m just telling you.

ERIN:         That’s good.

T-BONE:   I live in a house that has air-conditioning and has a roof so we don’t get mosquitoes inside.  And at seventy degrees I go to my garage, I get into my car and I drive to my office and I walk an entire two minutes from the car to the office and get to my office which is also inside and it’s seventy degrees and doesn’t have mosquitoes. And I run back to my car on the way out to the office and go into the garage and walk right in.  So ahm… [Laughs] [crosstalk]

ERIN:               Yeah, you’re set.

T-BONE:   I live a seventy degrees life as well.

ERIN:              Actually, I was so thankful this to past April first, and second that I go to see your office in action just what a beautiful office location right next to your wife like you’ve really designed it so well, you know, [crosstalk] I’m impressed!

T-BONE:   Thank you very much. And I don’t know, I don’t know if by pure luck that we achieved that but, you know, our office has problems, and that’s, that’s one of the things that drew me to you Erin was that, your practice is just like, in most of America, you work with insurance. You’ve got team issues. You’ve got positive and negatives.  You’ve got things that are going on. You have struggles. You have successes and too many time I find that many educators are living in the Ivory tower and they’re stuck in academics and not that there’s anything terribly wrong with that but they’re not really focus on the everyday work flow and how we live a life, how we pay off our debts, how we provide for our family and our children and how we continually grow and create professional satisfaction more than just financial satisfaction.

                   So, talk to us about your practice a little bit. What it’s like?

ERIN:        Well, well isn’t that the truth is that like we literally are there every day grinding it out and we go to a CE course and it’s like wow, this person has it all together. Wow, they don’t even take insurance. I want to do that. I want to be this fee for service.

Well that model doesn’t work everywhere you go and to be honest I would actually missed the families that I get to work with.  We are truly post [unclear] family dental.  And I still see little kids and do filing on little kids and I still bill medical insurance, but it’s or not medical, dental insurance and I listen to your debate the other day and I just thought it was so awesome and so real and that’s what I appreciate about you.

Well, what’s so funny is that, I taught the first day our course together in Raleigh by myself and when you came the next day we’ve literally said almost the same thing word for word that’s how in tune we are. But that’s also a testament to the daily grind of dentists.  So yes, we bill medical insurance, we still need new patients.  I work on marketing. I happened to have a partner who kind of does the back office stuff who does the accounting.  I do the front office, HR, try to manage eighteen people in a busy ten ops. [crosstalk]

T-BONE:   You have eighteen team members?

ERIN:              Yes, Ten apps.  We have a third dentist just on Thursdays and he’s just retired guy who’s almost a father figure and it’s so fun. But we have four to five hygienists at a time but I feel like hygiene is the engine.

                   Sleep apnea is not the engine, implants aren’t the engine.  Our hygiene is the bread and butter but that’s where we get our restorative.  And we’ve built, you know, hit the ground and really build up sleep apnea created.  I again, I live in a small town so to find a niche [crosstalk]

T-BONE:   Define, define a small county?

ERIN:         Post pop is twenty seven thousand.  Kootenai County that’s like forty miles down the area about a hundred thousand.

T-BONE:     What county did you just say?

ERIN:         Kootenai

T-BONE:   [Laughs] Oh God, I just snorted.  Ok, go ahead, it’s a back to back

ERIN:              It’s a Native American name come ‘on Tarun. It’s Indian.

T-BONE:     I thought you said something else. Listen, those are feathers not dots. I’m the dots kind of Indian.

ERIN:              Oh. Oh, oh sorry.

T-BONE:      I’m the dots kind of Indian. So, Ok I’ll let you continue, I apologize.

ERIN:              I say small town to the point where when you go to a restaurant you run into at least one person you know.  If I go to the airport at in Spokane, Washington I run into at least one person I know. I defined that as enough or if you advertised in the newspaper people will see it.

T-BONE:     So, how did you build this hygiene part of your practice? What do you do with your hygienist to, to build the practice?

ERIN:         You know we run on the hour, we do probably [crosstalk]

T-BONE:     You do one hour appointments?

ERIN:              One hour appointments, they reappoint.  We do exams as we can. They call us for exams as soon as possible not just as the end of the appointment, we – they’re all just so nice and educated and care about the patients and that’s kind of culture that we’ve created.

You know, our tag line is join our family but to us, it’s more than just  tagline, like literally, if  I see a patient on the newspaper I’ll cut it  out, laminate it, send  it to the patient. We really are a community and people that don’t subscribe to that culture don’t necessarily last very long.

We try to fit our hygiene we kind of got a little hungry at one point, because when hygienist had medical issue, so we kind of hired her back part-time but it wasn’t enough hours anyways,

Long story short our hygiene was hungry and it was empty and it was scary.  But that was just in my opinion, more opportunity to fit people in, to feed our restorative.  So if you come from this perspective of, of fear it’s not going to get you a whole very far.  But if you come from “Wow, this is just a great opportunity to fill our schedule”.  It’s amazing how we just had literally two weeks of what are we going to do?  To now, it’s totally fall and how I’m going to do all this exams?

T-BONE:     You know it’s interesting you saying these because I called the cost, the opportunity cost.  We’re running into this “now practice right now” because we’re booked out hygiene.   We’d like literally new patients and we call a book for month and a half to months out, and it’s a big problem and not a problem like- Oh my God it’s great as in a problem oh my God these is horrible and I’m booked out for consultations and, and any work until July now.

This is a big problem and what I tell people is we need to leave an open spot on our schedule every day because if you leave an open spot you will naturally fill it and typically you will fill it with unbelievably productive things because if you’re too busy, if you don’t have openings in your practice how are you going to get that person that calls in with a toothache that needs a root canal and crown?

How you going to get that patient who walks over from the neurology office and the neurologist calls and says hey, I’d like this patient for as sleep w consult, you’re like, oh I can see them in six weeks you know, that’s not, that’s not a good thing.

I think too many people focus on the answers to be busy, and I don’t think, being busy is the right answer.  Just like airlines they leave sits open purposely to be able to sell to your high price customers who forget to buy. People like me who forget to buy tickets [laughs] until the last minute.

ERIN:              Well, I have to tell you these T-Bone that we literally do leave blocks in our schedule till two days before and if you unblock it you’re in deep doodoo.  We keep it there so that if a new patient calls, not that new patients are more important than existing patient but you don’t want to create that feeling that we don’t have time for you and we always fill it, so we, we leave blocks in there for new patients.

And some people know how busy we are and will even say are you accepting new patients?  And I’ll say always, so our marketing, most of my marketing reflects toward sleep apnea only because that’s a niche that such as a part from all the other dentists, but if I do any dental marketing, If we do any dental marketing, then we, then my what we going to say in there is now accepting the patient no, we say always accepting new patients, because I’ve had, had enough people asked me that, that I don’t want to create these thought that we’re too busy for them.  We always have time for them.

T-BONE:     And, we should always be accepting new patients, that’s a good way of putting them.  We should always say, always accepting new patients   because you’re right patients oftentimes they think like are you accepting new patients, of course we are, right?  But the perception is, you know you said something to me earlier we were talking you said something about how you organically built your practice.  What, what   does that mean and talk to me more about that?

 

ERIN:              Well, I don’t know, if it’s coz I’m cheap or coz we’re in a small town but I don’t feel like we have to pay for SEO that we have to pay for Facebook.  We created a culture around our office and the team members reflect that as well. A lot of our, our new patients come from sleep apnea.  A lot of our patients because again we’re set apart and they’re like wow, we might as well just be a patient here too.  We also, if a patient has an enjoyable experience and we’re buddies, all of a sudden I’ll say hey, would you get on Google and talk about us?  I’ll advertise on the newspaper but again I try to limit my marketing dollars into something that works and in just a word of mouth.  So that’s   what I mean by organic. Yelp, Google all those things are free, all you have to do is asked.

T-BONE:     You know, and I think also organic means is sometimes you’re asking patients to refer other patients.  You know, and…

ERIN:              Sure!

T-BONE:      And many dentist thinks that’s a sign of desperation and really it’s not. it’s a compliment that hey, we’d love having patients just like yourself If you know anybody looking for a great dental home, we’re always accepting your patients and I think there’s nothing wrong with asking for referrals.. [crosstalk] That’s part of organic.

ERIN:              So many consultants give you verbiage.  Well, if you like your experience today then, no, just make it your own make it natural.  I have no shame when asking because I want more patients that appreciate what we do and usually like patients hang outs with those types of friends as well.

T-BONE:   Now, I always say people with missing teeth hang- out with people with missing teeth right, and people that’s snore hang-out with people that snore. It’s like a club for snoring people.

So speaking of sleeping and snoring, so talk to us about sleep apnea.  How did you get this started in your practice?

ERIN:              Well! The first step – was acknowledging that it was a need. The fact that dentist could be a part of it.  The second hurdle was the fact that I may change a bite.  In fact, I start out my lecture telling a story about Philly’s who, she had a posterior open bite and I was so mad about it and I sent her to the orthodontist and I am like you need to fix this but the Orthodontist sent back a note that said – no orthodontic treatment recommended at this time.

And finally, something clicked to my head like wow, her sleeping at night and getting oxygen for this you know?  Quality of life and life ending disease is more important than dying with a perfect bite and getting some of that that dental school brainwashing out of my head really helped.

The second was – so I went and trained and learned and I was so excited to offer this lifesaving thing but then no one went for it because we didn’t bill medical insurance.  So as soon as I kind of learn the medical insurance, it was like it hit the ground running, especially since I was one of the first in town. There have been several [unclear] but when it comes to sleep apnea it’s kind of like oh, go see Dr. Elliot, go see DR. Elliott, and it’s because I’ve really created a system that works.

My team is trained, we’ve learned the ins and outs of medical billing which is a pain and a big hurdle but it’s not such a bad thing that it’s a hurdle because they’re not anybody and everybody will do it. People who actually care about it and who would do follow – ups and treat it the right way, get into it so that’s were passions lies for sure but I’m still just as passionate about dentistry.

T-BONE:     Oh that’s good you know, sleep for me was a – is a more personal condition, because while my wife was in was in her medical residency I think she was tired of me snoring and I guess, one of her professors was talking about doing a sleep fellowship and she said, oh I’d like to just have my husband tested.  So I went and got tested with one of those in lab PSG and they hook you up to eight thousand wires and it turned out that I had the heavy moderate, high moderate apnea.

And they put me on CPAP and immediately I felt unbelievably better.   But the problem was about six months later I stopped using my CPAP because it got cumbersome.  I got a little bored of wearing it, I got tired of cleaning it, it smelled a little bit so all kind of stuff was going on there.

So you know those are some of the things that led me to start doing sleep and I think as the practice want to grow, they have to go beyond crowns and fillings to expand their practice. It’s a nice thing sleep is a great venue. They are so caught up on only working with MDs and feeling that all the referrals have to come from MDs and they get caught up on the medical billing part of it. And really, all of those things are easily overcome. I tell people that there are four steps to successful implementing sleep apnea in your practice.

One is you got to create awareness. Two, you’ve got to get an MD diagnosis. Three, you’ve got to make It easy for your patients to do the finances. And then fourth, you got to have a good treatment protocol. So how are you creating awareness in your practice, Erin?

 

 

ERIN:              You know every instructor has some sort of like screening tool or some sort of whatever, and really I think it begins with the conversation.  It begins with the relationship we already have with the patient.  Screening the signs and symptoms as you know, I kind of give you a sneak peek at what I call – I don’t need to have my name on anything but as the evaluator almost a checklist there’s so many dental signs and symptoms and [unclear] being a big part of that, hard palettes, large tongues, small airways.

We are literally on the front line as dentists. And I think it’s a shame if we don’t – even if we don’t want to do medical billing, even if we don’t want to  treat sleep apnea, even if we  want, don’t want to get into those ins and outs, we have to be screening, absolutely have to be screening and then referring to colleagues who wants to treat this.

It begins with the conversation with the hygienist and honestly I treated three out of five of my hygienist husbands and they are raving fans.  You, you just said how many percentage of the normal American population has sleep apnea. Well, my one, my hygienist thinks hundred percent of the American population has sleep apnea but it starts the conversation and one of the things she says is do you wake up refreshed? It’s not just about snoring even though ninety percent who snores has sleep apnea.  We know there’s insomnia.

People that just only refreshed even after a lot of long nights sleep, she’ll even get a mirror and say hey, I just want to show you your airway, here, I’m going to hold your tongue down.

Now I want you to look at the mirror, do you see your airway and the patients says no, she’s like exactly, you don’t have one so when, I don’t fill out screeners on my new patient exams or anything like that.

We start the conversation, but I also have a lot of MD referrals at this point.   It’s been seven, eight years by now. I also have patient’s sending their friends and family.  I have a patient drive for two and a half hours, I found them in Denis in his hometown but he’s like, no, I’ll just come to you. So, it’s just kind of creating awareness and do some marketing but just kind of finding a workflow and a passion. [ crosstalk]

T-BONE:   But if  somebody’s starting let’s say,  am brand new to sleep I would say that there’s nothing wrong in doing the sleep questionnaire that is a great way to start the  conversation.

ERIN:              Yes.

T-BONE:      The other thing that we, we recently implemented in our practice is we’re taking the Mallampati photograph.  Were we’re actually having the patient open up, stick their tongue out and we take a picture of their airway, with our camera and then we share that with the patients, so that way we can classify them.

And you know to me, it’s, it’s about creating awareness.  The other thing that we’re doing because I want to give people an opportunity how they can implement these in their practice is;

The other thing that we’ve done is we have signs up in every room in our office that ask the patients do you snore and would you like help with that.  You know I, I call that subliminal marketing to create awareness.

So, I think it’s unbelievably easy to create awareness.   I would say that if you can take the picture of the Mallampati and take the picture of the airway using a digital camera.  Number two: if   you can have them fill out a sleep questionnaire; number three – if you can train your hygienist to have reasonable conversation with people; number four – if you can subliminally market to patients using snoring as the hook line to get [crosstalk

ERIN:        Yes.

T-BONE: Because, who does, what wife doesn’t want their husband to stop snoring and what husband doesn’t want their wife to stop kickin’ them while  they’re sleeping?

ERIN:               I call that curing bruised ribs syndrome.

T-BONE:      Right!

ERIN:         But few husbands also denies that so. The nice part of about the Dental practice is that you usually see the wife so you get the real story.

T-BONE:      Yeah, of course.

ERIN:         If you’re going to use a screener, I totally recommend stopping over anything else, stop being spinner. Yes, very much so.  And then as far as ‘what you can provide, I don’t have this opportunity but the 3D Imaging.  If you’re going to be taking 3D Images on someone anyways, I would totally take advantage of that. [ crosstalk]

T-BONE:      Yes]

ERIN:               I just don’t have the opportunity.

T-BONE::    Yeah will work on that with you so, I would say what Erin is talking about is the ability to use segmentation, to show the patient their volumetrically.   What the airway looks like and be able to see exactly how it looks so that’s a great tool in creating that awareness.

So you know, we talk about awareness and now the second thing that people, and I find this unbelievably mind boggling that people get caught up on these, and that’s diagnosis.  So, who can diagnose sleep apnea?

ERIN:               Not dentist.  but, I have not diagnose one patient but I also have seen a lot of I’ve   diagnose a lot of people through the muddy buggy referral pathway that is medicine.  And that includes having my own home sleep test testing units. Sending the home, the patient’s home with them, if they come in for consult never have a sleep study I send them home with one of our four and have a sleep position online diagnose it.

So, I’ve never diagnose anything but we have utilize our own home sleep study units in order to get them to the referral pathway.

T-BONE:      So that’s good. [crosstalk – ]

ERIN:              Same as you right?] Right, you know in fact, I would say my biggest struggle in the beginning when I you know. I so, so I think what people need to understand is this is my second foray of sleep apnea practice.   We tried relatively successfully [crosstalk]

ERIN:             To play by the rules [laughs].

T-BONE:     Well, the traditional rules about four, five years ago and we had good success but we run out of patients ah you know, the patients that we got and then we basically stop doing it and then I got, I got irritated about a year ago.

This is the opportunity I know it’s the opportunity so we, we started getting smarter and I would say that dealing with the MD’s has been one of the biggest struggles that we had.  it’s a damn if you do, damn if you don’t relationship because you want to work with the MD’s but at the same time they’re the hindrance in getting more people diagnosed.

 

ERIN:         And guess who loses. Not us [crosstalk –

T-BONE:      The patients, the patients, No question the patient loses. so…]

We go from one month from start to finish to nine months of fighting uphill your battle.  As soon as I you know, I think, I think the saying is that women who follow the rules rarely make history, and  I feel like I’m such a rule follower but I was so frustrated and  my patients were  too that’s when I finally  took off.

T-BONE:      So you know, ultimately you get diagnosis you needed MD to diagnose and that diagnose has to come from an official sleep test be the HST or home sleep test or PSG in lab Polysomic Gramm, so, what you’re telling me is that you are comfortable dispensing an HST to your patients and then you have a board certified physician read those HST’s to give you your official diagnosis?

ERIN:              I do.  But I also am not eager to test to call enough to think that in oral appliance we’ll cure everyone. If they have co-morbidities I’ll refer [unclear] if they’re Medicare Medicare wont’ cover my study.  But if a patient is relatively healthy, doesn’t wake up refreshed, snores then gas, I feel totally comfortable with that and I haven’t lost any sleep, see, I’m all about good sleep.

T-BONE:   So, you know, I would say that I go probably go a little bit farther than you in the sense that those pay – here’s what I found is – I found that patients simply don’t want to go to asleep lab.  and, and they don’t, they don’t value or they’re not aware enough of their situation to want to go to a sleep lab. So, I find that doing an HST turns out to give me the data to be able to send them to the referral then to get to the MD, to get a more comprehensive test done. There’s so many things that can be going over sleep.  Sleep is not just breathing, sleep is insomnias, sleep is restless legs syndrome, sleep is so many medications, there’s so many factors that are involved in sleep that it’s not just breathing.

ERIN:              Right! But I’ll, I’ll refer for CPAP too.

T-BONE:      Yeah, of course, at the end of the day it’s doing what’s right for the patient. If the patient need a CPAP, they need a CPAP so you know, that’s, that’s fair enough.  So now, the diagnosis, so what is your take on people outsourcing the HST’s?

Would you recommend for people to simply buy their own HST machine and dispense directly, or would you recommend that they use a third party to deliver the HST for them?

ERIN:              Oh, it’s just depends on your set up.  My volume is much that it’s just easiest that if they come in for consult we send them home with one and we do enough of them. But you know, there are some third party HST people that help you eat up deductible and it’s not you, dealing with it but you know, everyone’s practice is different so I hate to give a blanket answer on that.

 

T-BONE:      We’ll I’ll be bold enough to give a blanket answer, how about that? [Laughs] crosstalk- thank you] So, here’s what I would say is, there are great third party companies out there but I believe in vertical integration. I believe in having it in office, because every step, an additional work to the patient has to do with another barrier before patient can accept treatment.

So, there are times were we know the patients meet the deductible.  We know they have a problem but our patients sometimes just aren’t willing to spend a hundred bucks on HST and I’ll eat the hundred dollars for them because it’s so important for me to get them tested and from a business perspective, I need to get them tested to get them into appliance.

So, I’m   a firm believer in vertical immigration, I believe that if you’re truly serious about getting started with sleep. I didn’t say get serious about being like an expert in sleep, I’m just saying getting started at sleep.  I believe you should invest in HST machine.  Have it ready to dispense directly from your office, to make it easier for your patients and therefore easier for your practice.

ERIN:              I, well, I think that’s an absolute no matter what. I think it’s an absolute because you’re going to, you’re mean to do follow-up HST as prior to you know, sending them back if you do, I’ll just send the results back to the physicians bill, here ye go, they’re treated.  But even if no matter what, you need to have one of them, and your, I think you said that if you come take a course, your goal could be four to six appliances a month.  That would easily pay for a home sleep test.  But you could do way more than that. [crosstalk] What?

T-BONE:      But Erin,  I think what happens sometimes is- we’re both guilty of these. You more so than me is that we forget what it was like when we’ve started.  You said, you’ve said things like hey, you know I’m doing that volume now but our average listeners just, just wanting to get started right, so, so…

ERIN:         Yeah, but I still think you need to have one. Even if you are just getting started.  [crosstalk]

T-BONE:      No, no of course.

T-BONE:      No, no that’s, that’s my point but is that, you, you need one.  I, I think to look; I think if you want to get into something be serious and be ready to do it or simply don’t do it.  Either, you can do MOD’s for the rest of your life or you can get serious about doing something that would really change your patients’ lives and your practice lives.

So, we’ve talk about awareness, diagnosis and now let’s talk about finances and finances is part medical billing.  So ultimately, you have to make it easy for your patients to say yes and we know that money plays a big role in many people’s ability to say yes to what they need.

So how does medical billing play a role in sleep apnea?

ERIN:              Well, I actually, I have an article coming out in Dental Economics, it’s  going to be a recurring article on medical billing but the first article is about ‘What I Did Wrong?”  And the first thing I did is, I don’t want to learn medical billing.

I’ll just have the patient pay up front and give them the codes and hope they get reimbursed and I did like three. [laughs] They were really desperate and independently wealthy.  But as soon as we took on medical billing that’s the medical model, you’re used to that.  And it’s not that hard.

We deal with three or four codes.  Once you get the hang of it it’s not that hard and it’s a huge service to your patients but we get reimbursed, it depends, Medicare, blue card, I mean everyone’s allowable are different but on average because it’s ninety percent delegatable, it makes it completely just gravy on top of your already busy general dental practice. Again, it’s not anything that we’re doing full time, and  just integrating these has just allowed for that  much more production  but in collection mostly, just really, really happy, happy patients that need dental work as well.

T-BONE:      Yeah, you know I tell people, I said, they say why do I need sleep? I’m, I’m doing good enough now and I’m making enough money and I go well sometimes it’s not about those things   but I say, what happened to professional satisfaction you know, how many times have you done an MOD and your patient got up out of the chair and said thank you for MODing me that was awesome. [laughs] Right?

ERIN:         That happens a lot for me,

T-BONE:      Yeah, I bet, I bet, being blonde and female I’m sure that helps. [Crosstalk- yeah]  I think we’ve lost that touch of that professional satisfaction and the passion that it creates when you’re able to help somebody when, when, when you know, when I see a husband for sleep apnea and we do treatment and the next time we see them for follow-up they bring their wife in with them and the wife says thank you, you know, you’ve really help our marriage out.

Those  are wonderful things so,  I think  in terms of  what I would  tell the listeners if you try to look at how you can make this more affordable for your  patients I would say;

Number one – medical billing– it’s one of the easiest and most predictable claims to get paid, if you play the game the right way and unfortunately it’s a game but you got to play the game the right way.

And with medical billing, ultimately it’s easy you got to do eligibility, you got to get  diagnosis and your  pre-authorization and then you submit your claim and then you claim follow-up.

It’s a pretty easy process once you get it but the problem is it’s so foreign to most people that it’s so outside of what we do on a daily basis that we never give it a time and effort that we need.

Secondly- The thing I’ve, I’m a big advocate of is in office payment plan.  So when your patients does have the co-pay or the out of package expense make it affordable for them by allowing them to make payments by credit card  over a few months  to make it easier for your  patients.  And, and then… [ crosstalk] go ahead

 

ERIN:         No I’m just going to say the other part of it is, that  by the time Brit and I have done talking to him they see so much value that they don’t care what  it cost.  In fact, I had a patient who did a video testimonial the other day.  He’s like, I have a high deductible but I didn’t care because  the way I feel I had two.  And with CPAP there is an ongoing cost but with the appliance there isn’t, and just building the value into it, it doesn’t matter what it cost out of pocket.

T-BONE:      Yeah, you know, and so, so that’s a good point.  You keep talking about Bri, who is Bri and, and how did Bri come about and what does she do for you?

ERIN:              Well!  She’s my dental, sleep medicine coordinator. She was a clinical assistant and I said, Bri, I need someone to take these over and two weeks you’re going to start, Here ye go and we went from A to Z but just someone that enjoys the challenge. Someone  that takes ownership, someone that cares about patients, someone that’s organized.  I can’t take credit as being that sleep apnea guru without her and that’s why and, that she just kind of see so much of my patients on the third column while I’m doing two columns of dentistry.

T-BONE:     How did you get Bri into that stage?

ERIN:               I mean some of my own trainings, some my webinars going to a course, going to courses, treating her father just creating these. She really just took it on as if it were  her own, some ownership with that as well. It wasn’t monetary, I tell you that.

T-BONE:      So ok, so do you… [ crosstalk]

ERIN:         There was a raise. But not like a huge bonuses or anything.

T-BONE:      So, let me ask you this; so, if someone’s just getting started did they have to have dedicated person to sleep?

ERIN:              Personally, I would recommend it.

T-BONE:      Ok, could that be an existing dental assistant that does it on the side to  a certain degree that owns it and then as, as the business comes more, you know as the business demands  they could transition to it that essentially Bri that’s all she does, correct?

ERIN:              Yeah, but that’s how it revolved, she was my chair side.  She’s still is from time to time but it’s someone that wasn’t necessarily the lead assistant that does everything that does all the ordering that like it’s so easy that just pile the stuff on to the assistants that do take leadership and ownership.

It might be someone that it’s kind a more of a [unclear] but someone that really cares and is passionate about it because if you pile more to someone who already has enough then is going to be a breaking point.

I just identify people when I go in the offices and train them; I try to identify people that really are organized but also passionate about it.

 

T-BONE:      Ok, that makes sense.  So, I think that’s enough from sleep. I think what I would tell people is you know, listen! If you want to get serious about sleep and many choices, certainly, you can attend some overall conferences that will get you motivated and inspire you to learn the basics about sleep.

I would tell you that Erin and I went to unbelievably workshop that’s two days and we encourage you to come and encourage you to bring a team member and will walk you to our process.  I think what makes us unique is that we focus on the workflow of how these is working in our practice me coming from our perspective of someone whose about a nine months to a year into our journey and some of the mistakes we’ve made and Erin, who’s five or six years into journey is really establishing herself as an expert with sleep apnea whose cultivating the MD relationships.

I would tell you that if you’re saying hey, I can’t do it because I can’t get diagnosis’s  I would say get an HST,  if you say, hey I can’t do it because  I don’t   have a referral network,  I would tell you that you don’t need a referral network to get started and that over time  you will naturally build a referral network. as you send these patients back.

So, I would encourage you to consider coming to some of these classes and certainly it, it’s not just us.  There, there are other great instructors there’s Ken Smith in Texas who does a fantastic job and…

ERIN:               He’s awesome.

T-BONE:     Yeah, Ken is fantastic, so there are many other choices you know.  I never tell people that we’re the only choice that they need to see us.  I tell everybody that when it comes to instructors, and when it comes to learning something you have to really  resonate or connect with the, with the workshop leader and if you connect with Erin and I  our style of practice then certainly that’s a good option for you. But you know that, that’s up to you.

You can visit 3D-dentist.com to get more information.   So Erin, we’ve got about five or six minutes left, let’s talk about, let’s talk about  your practice a little bit. What are some of the challenges that you’re facing right now in your practice?

ERIN:              Well, I haven’t had to say it’s always team.  I think I have eighteen employees now and I got to be the HR Manager coz they totally teach us about that in the dental school.   But saying that it’s kind of having team members that do more than just show up to work and unfortunately, I’ve had some hurdles along the way and I have to realized that everyone is replaceable.

Unfortunately, even Bri, but having a team and a culture where everyone wants to help each other, where everyone does their job.   I’m not much of a micro manager which can get me in trouble sometimes as well because I’m like I do my job, I just assumed other people do.

You know, I think that’s probably the biggest hurdle like I hold my breath every morning like ok who’s going to show up late today?  Who’s going to be sick?  They have to report to me and sometimes they got scared because they know I’ve only missed one day in thirteen years and that’s because I had like a deathly flu but I don’t…  I mean do you see the same thing?

 

T-BONE:     Yeah, I would say, you know, I  will, for me, I think my  number one challenge is me. You know, I’m so distracted and am pulled in so many directions, but if, if, outside of myself i would say it’s my team members as well.

I’m keeping them motivated, keeping them happy, keeping them, keeping pushing them and having them push me.  I would say, and from me we went to massive turn over at the office  last year, some, most  of which on purpose, some of which not on purpose, we’ve gone to maternity and the last six months  we had two people pregnant, so …

ERIN:               If people could just have getting knocked up, it’d be great!

T-BONE:     Yeah, that would, that would be a lot better if that could happen.  So, if you don’t mind I think it would be very humanizing if you shared what you can about  some trust issues that  you’ve seen happened in your practice and what that can lead to and what that  taught  you and what you’ve recommend to other people on that?

ERIN:               Yes, I would love to, and these is very humbling because I feel like at this point yeah, I have on my crap to go that should never happen.  But it’s just same old story that’s everyone deals with.

I’m not a micro manager, I ‘m all about delegation but   unfortunately, with delegations comes people who feel entitled and I had an office manager that really just really busted her butt.

Worked hard, we worked well together.  I wasn’t her best friend or anything but I really trusted her and she took advantage of me and fortunately we caught her on time but not to go into details just coz I can’t but I… the numbers weren’t adding up and when they were questioned there was always a reasoning, always an excuse, always something that I believed, because you know, no one will take advantage of me because   we’re good people, we worked hard.

T-BONE:      And we all love each other.

ERIN:              We all love each other but at the end of the day as I’d love to say, is that, It’s my practice and no one’s going to love it or take care of it as much as me and my partner do. And because there was a partner, I think that she was able to work that angle a little bit as well, but you need to have checks and balances which we did and which we do but we didn’t always follow it through.

T-BONE:      We didn’t check, we didn’t check that checks and balances.

ERIN:              Correct, and it’s embarrassing but fortunately we have, we had team members that were much more in tune than we were and we were able to finally address it but again, it’s so kind of in limbo right now but it was, it was really stressful.

So, It’s one. Some of the most stressful two months of my life and fortunately again I’ve heard horror stories but it was probably to the tune of they ended up this detective ended up finding fourteen thousand dollars’ worth of checks that weren’t even deposited.

She didn’t steal them. They’re just weren’t ever deposited into the bank coz she was taking the deposits to the bank.  So all entirely adding on one another real number of her actually like pretending to work in our office and not being productive and unhappy patients and all those things.

You can’t put monetary value on that but it was the first time I’ve been taken advantage of and it’s really well, humbling for us about that just makes you sick to your stomach and makes you not trust people that you really think that you should trust.

T-BONE:      You know, they say, fifty percent of dental practices are embezzled at some point in their career and you know, I’m sure it’s happened to, I’m sure it’s more than that and a lot of people don’t know but ah, I would say it’s a lesson to all us to never trust somebody with so much.  To always have checks and balances and to always go through those checks and balances.

ERIN:               Yeah, follow through with them is a big thing…[laughs] yeah!

T-BONE:      Yeah, So, so what’s next for Erin Elliot?  What, what do you got going on, what, what is your next goal in life?

ERIN:              My next goal in life. That’s a great question.  You know, I wish that I was the type of dentist that could just show up to work and go home at night but I always continue to challenge myself to be better to educate myself, to stay on the cutting edge of dentistry because it’s really exciting what’s going on and for to be content still doing amalgams is not my lot in life.

I want to continue to help my patients as well as either for my family and that’s I think the joy of our career.  You know I’m a Latin nerd so I called it our vocation because in Latin,” voco”  means calling and I feel like I want to inspire dentists to be  more than just  dentists but also to go above  and beyond for, for what we’ve been blessed with.  Is that sound cheesy? Are you crying? [laughs]

T-BONE:      No, I’m not crying, but…

ERIN:         [Laughs]  It is true.

T-BONE:     It is, it is cheesy but there’s nothing wrong with being cheesy and you know if there, I listen, I think we’re getting to the time, so I leave us with this message.

First before I do that,  Erin, if somebody wants to get in touch with you what’s the best way?

ERIN:              Oh!  I, I love emails. ErinElliottdds@gmail.com- but I have two l’s and two t’s

T-BONE:     Yeah, we never know who you’re sending those emails to right?

ERIN:              E-r-i-n-e-l-l-i-o-t-t-d-d-s@gmail.com

T-BONE:     That’s great, and if you guys catch me sleeping somewhere I might give you her cellphone number so you can text her at night,..

ERIN:              Add it to my lecture,

 

T-BONE:      Yes, exactly, so, you know I think, it’s been a great conversation and thank you for coming now and thank you for sharing your time.  I know there’s a lot going on in your life with the Gmails, you know they’re keeping you busy and your husband as well.

So, you know, here’s my message to everybody, it’s easy to find excuse of not doing something. It’s easy to say I’ve tried sleep apnea and it didn’t work.  It’s easy to say hey I’ve tried medical billed for sleep but it didn’t work.  It’s easy to say hey, I’ve tried to develop relationship with the MDs but it didn’t work, but what I can tell you if you say it’s easy to do those things and you allow that to be the case, then you have no reason to complain. You know, you should be happy with what you have.

But if you want more for your patients, if you want more for your practice, more and more for your family there’s nothing wrong with wanting more for your life and there’s nothing wrong in earning more for your life and helping others.

I would tell you that professionally sleep apnea has been an unbelievable professional satisfaction for us.  Its allowed my team to grow. it’s allowed my practice to grow and it can be a great spring board to lots of other things for your practice and it needs a great procedure.

So I would encourage everybody to get serious about sleep and to look at what possibilities are.  So, Erin anything else from you?

ERIN:              No, I just thank you, now you don’t have many guests on so I’m pretty honored to be one of them.

T-BONE:     Yeah, yeah, you know?

ERIN:              Yeah, please feel free to reach out to me I really am available and, just like you guys going to the grind of daily dental practice, so, give me a shout

T-BONE:   Thank you Erin.

                                                                                                          

Thanks so much for listening to T-Bone Speaks with Dr. Tarun Agarwal. Remember to keep striving for excellence and we’ll catch you on the next episode.

Thank you everybody and I appreciate your time.

Thanks so much for listening to T-Bone Speaks with Dr. Tarun Agarwal. Remember to keep striving for excellence and we’ll catch you on the next episode.

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