Practice Building Strategies to Kick Start the Decade

Coast to coast, there is a significant variation in the approach of physicians who provide phlebology services. Some practices are cash only. Others may focus almost exclusively on Medicare patients. Many have a robust aesthetic program while a few offer no aesthetic services at all. All of the successful practices, however, regardless of payer mix or approach, have some notable features in common.

AJ Riviezzo, CEO of American Physician Financial Solutions, shares his insights from assisting nearly 20 phlebology practices nationwide. His observations and recommended strategies, noted below, are a toolbox of “best practices” that you can apply to help build or sustain the successful momentum in your own phlebology practice.

Know Your Primary Focus

From the physician to the receptionist, the primary focus of the practice is phlebology. The schedule, the telephony system, the equipment and the people are all dedicated primarily to providing excellent outcomes for the treatment of venous disease. This does not exclude providing a strong and vibrant aesthetic program. Merely that the focus of the practice is phlebology and the successful treatment of the patients for this medical condition may heighten opportunities for the patients also seeking aesthetic services.

The practices that have done extremely well in phlebology are those that, not surprisingly, are focused and dedicated to phlebology. This focus comes through in their approach to the patient and in their marketing. It allows them to tout their experience in treating this disorder to the patient who is concerned on multiple levels. It creates a sense of
expertise throughout the community. Most importantly, it helps ensure consistent physician, patient, and family referrals - generating even further success. Eventually you and your practice become recognized as THE place to go for treatment of venous disease.

Treat Customer Service as a Core Business

You really have two core businesses. The first is the business of medicine. The second is the business of customer service. All too often the second business, customer service, is shortchanged. Your patients (your customers) are choosing to have an elective procedure. If the quality of the interactions they, the customer, have with your staff, your telephone system, or you is excellent; then you must be an excellent practice. Patients assume you are a good physician. The patient requently gauges their care not on the actual care delivered but on their overall experience.

Successful practices have a very good appointment system. Calls are answered by a person, not by a machine.

Appointments are made in a prompt fashion and are not rescheduled - at least not very often. The staff has an air of competency allowing the patient to be hand-held throughout the process. Procedure appointments are made and understood by the patient. Follow-up/after care appointments are also made well ahead of time. Most importantly, the staff is friendly and actually smiles, and so does the physician.


One old adage is that having a business without advertising is like winking in the dark. You know you did it but no one else does. Successful practices (and any other business typically) have a robust marketing campaign. This does not mean you have to pour money down a marketing drain. There are a number of marketing opportunities available to a practice that are very low cost... but do require a fair amount of physician involvement. That being said, there does, at some point, need to be an investment in your marketing efforts. One formula i have seen applied is to spend between five and ten percent of your income on marketing efforts. As you grow, more marketing monies become available to help further build your practice.


As it is an elective procedure, while also a medical condition, many patients have an expectation of what the practice should look like... which is a cosmetic surgery office. If your waiting room, your exam
rooms, and your procedure room do not match the mental picture your patients have, it is an issue. Patients cannot gauge your surgical skills. They assume you are an excellent physician. They will, however, use other indicators such as your lobby decor or the design/appeal of your examination room to formulate part of their opinion about you as a physician and your practice.

Successful practices pay close attention to what the patient is seeing. Are the magazines forever old or are they routinely refreshed? is the furniture neat and clean? Are the walls looking old and a bit beat up or do they have fresh paint or paper? I am not recommending that you go out and purchase ethan Allen™ style furniture for every room in the practice but care and attention to detail must be applied -- even on a budget.


The impact of a good (or bad) sonographer cannot be overstated. excellent practices have an excellent sonographer. Their impact is felt on a number of levels.

First, a good sonographer will be able to help diagnose the patient properly. One practice had a so-so sonographer. She found reflux on perhaps forty percent of the patients coming into the practice. After she left and a new, more experienced ultrasound sonographer joined the team, that percentage jumped up to seventy-five percent. The practice then called some of the former patients that originally exhibited no reflux to come back for a follow up examination. Over half of these patients showed significant reflux.

Second, a good sonographer will help the physician gain access the first time, almost every time. There is nothing more frustrating to everyone, including the patient, for access to be attempted four or five times... and then have to abort the procedure because the target vein is now in spasm.

Third, your good sonographer helps identify patients that need an anterior accessory, perforator, tributary, distal
portion and the like to be closed by ablation or sclerotherapy. The patient, receiving comprehensive treatment, has a much better long-term outcome while the practice is rewarded by the compensation for their services.

Finally, your sonographer spends as much or more time with that patient than anyone else on your staff. They
need to be prepared to answer questions the patient has regarding their course of treatment, the practice, the staff, and anything else that develops. if your sonographer is not a people-person, delivering excellent customer service, the practice will suffer.


Your practice has to have goals. They need to be set for each month, each quarter and for the year. Someone has to be driving the practice. Based on your practice location and demographics, you should know that to reach X number of ablations for the month you will need to have Y number of diagnostic ultrasounds which was generated by Z number of consultations. if marketing is not producing that Z number, you will not achieve the desired goal for the month (and likely the following month as well).

It is not always the physician that is the practice driver. in some very successful practices, it is the practice manager that works to ensure these numbers are identified and met. in some other excellent practices it is the spouse. Regardless of who the person is, the physician, the practice and the practice manager must then act in concert to review upcoming appointments and ensure the formula, noted above, is being met for your practice.


Successful practices have two elements in the financial arena that are working for them hand-in-hand. The first is
attention to coding and billing of services and the collections work that follows. The second is the profitability margin.

In regard to coding, billing and collections, you must ensure that all of your potential charges are actually being
submitted. All too often i have seen practices lose money by not submitting all charges, not sending records upon request, or working the denials in a timely and succinct manner. Another way practices tend to lose money is by not being in compliance with authorization policies. The authorization process is your first step in being actually paid for your services. i also recommend that someone communicates,up front, with the patient about their financial responsibility. All too often these monies are left to be written off and now constitute upwards of twenty percent of your revenues.

As for the profitability margin, this will be different for each practice. You should know at what number of procedures you begin to make money. Most of a practice’s costs are fixed costs. i include employees as part of your fixed costs because you are not adding/reducing staff based on volume typically. if you need 15 ablations a month, along with attendant services to break even, then ?0 ablations a month will generate an income to the physician. increasing the number of ablations to ?0 a month will not create a large increase in expenses but will generate significant profit. in short, incremental increases that can be absorbed by your current staffing patterns will generate the most profit for your practice. Successful practices are aware of this fact and use it to help define and achieve their goals and target points.

One way to gauge your profitability is to divide total expenses (excluding physician salaries) into total income.

This is an easy profitability percentage go monitor from month-to-month. established, profitable and well-managed practices float between fifty and sixty percent. if your percentage is higher than seventy-five or eighty percent, and you are an established practice, this can be an indicator of a problem. There are two elements to focus on at this point. First, are you at your targeted goal for number of ablations and secondary procedures? if not, you know it is a marketing issue. Second, if you are making the practice goals you had established, you have an expense issue and really need to focus in on this element.


As previously discussed, you have a phlebology practice and a customer service company. Balancing the two issues when hiring can be tricky. Your ultrasound sonographer has to have a certain level of technical skills. The practice manager needs to have some core competencies to be able to help you manage and care for your practice. with that caveat aside, my strong recommendation is to always hire for personality rather than experience. You can train people to become better sonographers. They can go to a number of seminars or you can bring someone into your practice to give added instruction and confidence. You can send a practice manager to some classes or to begin taking the Medical Group Management Association set of on-line tutorials. what you cannot do is change someone’s attitude. if they are the world’s best practice manager on paper but
cannot work well with you, with the patients, or with the rest of your team, they are a burden. if the sonographer
is great but abrupt with the patient, unwilling to answer questions fully, and to be a source of positive experience
for your patient, they are also a burden and not an asset. it is always a ‘guess’ when hiring but look for folks with a positive, sunny, caring disposition. After all, that is what you would like your practice to convey to the outside world.
The best phlebology practices have in common a staff that exhibits this care and concern for the patient.


A concern that the above section on hiring creates is the cost in finding these people. Please know that finding coworkers with the right attitude does not have to cost you any more than finding ones with a bad attitude.
Sometimes they are less expensive because they may be a bit less experienced (and less jaded). My recommendation for any position is to pay a bit above market rates. For example, the going rate in your area for a good medical receptionist may be $13.00 per hour. I would pay $15.00. They are happy. You will be happy.
The extra $2,000 per year is the same as one extra ablation. if they help make your patient happy and your patient comes back for their next procedure, they helped pay for their small bit of salary over standard.

Bonuses can be trickier as they rapidly become part of the salary and not a bonus -- especially if it is paid in cash. if you always pay a $500 bonus quarterly to your sonographer, regardless of performance either by the sonographer or by the practice, you have just increased the salary and not given a bonus. Cash bonuses must be tied to something that is concrete. For a practice manager, it can be tied to the profitability percentage or to some other measured standard. For the sonographer, it can be linked to the number of ultra sounds performed or perhaps to the percentage of patients that return for their one month follow up ultrasound. now your sonographer is vested in your aftercare plan rather than seeing it as a burden. i do, however, strongly caution against any bonus being tied to finding reflux.

Another way to bonus people is with non-cash (but has a cash value) items. if you have a condo on the beach or in the mountains, perhaps your practice manager and their spouse get to use if for a week as their thank you ‘bonus’. One possibility is to give (lease) your key person a company car to drive. Rather than increasing salary they now get to drive a very nice car. That will certainly be an incentive for not only staying with you and the practice but to be further motivated for its continued success. Some of these ideas may also have a positive impact on your tax burden. Finally, a gift card to their favorite restaurant or store is always a nice thank you. Check with your
accountant when considering some of these options.

The best way to bonus people is to catch them doing something right, and to thank them. This is especially true
for your front office team members. Your nurse or medical assistant sees you a lot. Your front receptionist may hardly ever see you. A kind word, given in the moment, will mean more to them than a twenty-five cent pay raise.


Most physicians are great physicians. why, then, do so many seem to spend their time as a not so great accountant? Successful phlebology practices have learned a key secret. The physician needs to spend his or her time either working as a physician, or, if not enough patients are at the door, marketing to other physicians. If your take home is $350,000 per year, that means you make over $200 per hour. why not pay someone ten percent of that, $20 per hour, to do your books for you. One extra patient, two extra ablations per month more than covers that cost. Yes, you should review financial and operational reports. Someone else should be creating them for you. The above holds true for virtually all other tasks. Spend your time wisely and pay someone for the small matters that can drive you crazy.

In conclusion, there are a number of strategies you can employ to kick start the growth of your practice in this new
year and decade. The good news is most of these do not require continuous maintenance. Develop a short check
list and, perhaps at the beginning of every month, review each of these topics. Do a walk through of your pra tice
and see what the patient may see. Check your incoming appointments and new patient volume to see if it is what
you had targeted. Take a look at your financials and use a financial dash board that tracks key indicators from month-to-month. Above all, your energy and enthusiasm for the treatment of varicose veins translates to the staff and to the patient.

For more information, contact AJ Riviezzo, CEO of American Physician Financial Solutions, LLC, The Experts in Phlebology Consulting and Billing, at [email protected] or visit