Anesthesia Business Consultants: Communique spring08

Spring2008 Volume13,issue1
ANESTHESIA
BUSINESSCONSULTANTS
What is your Cost
per Anesthetizing
Location?By Jody Locke
Whether your practice is currently
engaged in a hospital contract negotiation
or not, it is hard to ignore the daily
balancing act of scheduling available staff
to best meet administration and surgeon
expectations. If your practice is like most,
discussions of coverage requests, new
venues, and other clinical opportunities
consume considerable amounts of time
at group meetings. The real question is
how you resolve such discussions and
what criteria you use to make objective
assessments of each request.
Obviously, the challenge lies in the
fact that coverage and call determinations
are both financial and strategic. The
financial part of the equation should be
the easiest part, but somehow it is not. It
should be easy to determine whether the
economics of a venue justify the level of
coverage requested, but somehow this is
the hard part. Deciding what is politically
in the best interest of the practice
invariably determines the outcome.
This aspect often seems easier and safer.
Such logic can be rather short-sighted
and, too often, practices find themselves
teetering on the brink of disaster because
of decisions that were made months or
years earlier.
Just as parents are advised not to
permit what they will regret tomorrow,
ABC offers The Communiqué in electronic format
Anesthesia Business Consultants, LLC (ABC) is happy to announce that The Communiqué
will be available through a state-of-the-art electronic format as well as the regular printed
version. The Communiqué continues to feature articles focusing on the latest hot topics
for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia
practice administrators. We look forward to providing you with many more years of
compliance, coding and practice management news through The Communiqué. Please log
on to ABC’s web site at www.anesthesiallc.com and click the link to view the electronic
version of The Communiqué online. To be put on the automated email notification list
please send your email address to info@anesthesiallc.com.
➤ Inside this issue:
What is your Cost per Anesthetizing Location? . . . . . . . . 1
The 2008 MGMA Cost Survey for Single Specialty Practices 2
ABC Organizes the Kickoff Meeting of the WAAAG . . . . . 8
Anesthesia Group (Un)Governance . . . . . . . . . . . . . . . . . . 9
Succeeding At Negotiations . . . . . . . . . . . . . . . . . . . . . . 10
Compliance Corner: Oig Workplan 2008 . . . . . . . . . . . . . 12
OR Succession Planning . . . . . . . . . . . . . . . . . . . . . . . . . 14
Event Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Continued on page 4

The Communiqué Spring 2008 Page 2
The 2008 MGMA Cost Survey
for Single Specialty Practices
by Joe Laden
Business Manager, Anesthesia Associates of Louisville (Ky.)
You are at the negotiation table with
your hospital administrator to discuss your
subsidy request. You slide your proposal
over to the other side of the table. The
hospital’s subsidy verification consultant
takes your proposal and at the same time
pulls a copy of the MGMA Cost Survey
from her briefcase and says,“Let’s see how
your numbers compare.”
Do you panic, not knowing if the cost
survey will support your proposal, or do
you smile with confidence because you
know your numbers line up favorably with
MGMA’s data from similar practices?
If your practice is to be measured
against others using the MGMA
Cost Survey, it is imperative that you
participate in the survey and have
your numbers counted. The higher the
participation rate, the more useful the
survey will be.
Picking the Right Battles
I am pleased to share another issue of
the ABC Communiqué with you. It is always
an interesting challenge to decide which of
the many timely and interesting submissions
we should include in our anesthesia practice
management journal. So many topics seem so
important at the time they are identified; it is
just not that easy to know which ones will truly
impact the future of the specialty. As recent
events have clearly highlighted, sometimes the
battles we steel ourselves most for, ultimately
resolve themselves. Too often it is the seemingly
insignificant sideline that consumes our time.
Let us hope that the ABC crystal ball is reliable
andthatwehaveonceagainidentifiedtopicsand
opportunities that will be relevant and useful to
you in the management of your practice.
Consider some of the challenges that have
become hot topics at recent anesthesia man-
agement meetings. Only a year ago we were all
bracing ourselves for another reduction in the
Medicare Conversion factor. Despite all the dire
predictions, the rate was increased by a larger
percentage than I can remember ever having
been approved for a single year. More recently,
Aetna appeared to be destined to set a prec-
edent that would change reimbursement policy
for endoscopic anesthesia; a disproportionate
amount of time was dedicated to this topic at
the ASA Practice Management Conference in
Tampa. Once again, wiser heads prevailed and
Aetna backed down. PQRI would appear to be
next in line as one of those public issues that
confuses and confounds our clients. The con-
cept is simple enough; provided that CMS and
the insurance plans could agree on a set of cri-
teria and a mechanism for paying practices for
their compliance. My read on this one is that we
are all in a wait and see mode. Meanwhile, an-
other drama is playing itself out in HCA board
rooms across the country. Having shelled out
close to $96 million in anesthesia subsidies last
year, the company has gone on the aggressive to
control its anesthesia costs. We can only hope
this remains a HCA issue, but I hardly think
we will be so lucky. There is a reason anesthesia
incomes only went up about 1.8% last year as
compared to the 10.6% the year before. Hospi-
tal administrations nationwide are really push-
ing back on anesthesia requests for support and
the traditional arguments are just not working
so well any more.
Each spring the American Society of
Anesthesiologists Conference on Practice
Management provides us a timely reality check.
Program Chair Robert Johnstone, M.D., who
assumed the position of ASA’s Vice President
for Professional Affairs when Alexander
Hannenberg, M.D. was elected First Vice-
President last fall, described ten issues that are
defining the future of anesthesia practice. These
included “healthcare reform resulting from the
2008 congressional and presidential elections,
marketplace battles over payer policies,
workforce scopes of practice, and the roles of
anesthesiologistsinperioperativecare.”Thriving
in this changing environment, according to
Dr. Johnstone, will involve “enlarging the
perspective of each issue, understanding the
drivers of change, and including regulators,
legislators, and public citizens in the solutions.”
The 2008 ASA Practice Management
Conference consisted of more than twenty-
five presentations on topics both timely and of
enduring interest. The dominant theme was – as
it has been for several years, consistent with our
experience – preparing
financialinformationand
negotiatingwithhospitals.
Summaries appear in the
ASA Newsletter and in
the very valuable compendium of abstracts that
you may order from ASA. For those of you who
are not aware of this annual meeting,let this note
serve as an introduction to what has become the
most important practice management meeting
of theyear. Theconference,andtheabstracts,are
a good place to start your own strategic review
and planning process. They certainly helped us
kick-start ours.
Another fundamental management
topic, understanding comparative costs per
anesthetizing location, is the focus of the lead
article in this issue of the Communiqué. We
hope that this article and others here will help
youtomanageyourpracticesmoreproductively
and give you a few valuable insights that you
could not find anywhere else.
Please know that we always welcome
commentsandfeedbackonoureditorialchoices
as well as suggestions for future topics. Nothing
would please us more than to have a reader
contribute his or her assessment of a key issue.
It is never easy to pick the right battles, much
less to know how to resolve them definitively. If
there is one thing I have learned over the years
no matter how good our individual judgment it
can always be honed with the critical experience
of experts.
Sincerely,
Tony Mira, founder and CEO

Your participation in the survey will
result in many benefits, including:
• MGMAmembersreceivefreecopies
of survey reports in which their
organization participates. The non-
member price of the Cost Report
is $500, and the price to members
who did not participate is $285.
• You will obtain a free customized
ranking report benchmarking your
practice against its peers.
• Youwillqualifyfordiscountsonthe
Cost Survey Report CD. The in-
teractive report CD has additional
information and stratification not
available on the printed report.
• You may participate in the MGMA
“Performance and Practices of Suc-
cessful Medical Groups” and receive
a free copy of this report. (Non-
participating MGMA member cost,
$300; non-member cost, $515.)
Better performing groups may be
highlighted in this publication and
receive an award certificate.
The MGMA Cost Survey for Single
Specialty Practices can be used to
benchmark your practice against other
anesthesiology practices nationwide.
Some of the practice parameters that can
be compared are:
• Charges and collections per provider
• Revenue (collections) per ASA unit
• CRNA costs
• Fringe benefit costs
• Billing costs
• Costs per case and per ASA unit
• Accounts receivable aging and days
in A/R
• Charges by payer
• Number of support staff and costs
per anesthesiologist
• Financial support for operating
costs (hospital subsidy)
For those of you who regularly com-
plete the MGMA surveys, you should en-
courage your colleagues in anesthesiology
to do the same. This applies especially to
colleagues who have not completed the
survey in the past and who have called you
asking for survey information.
A high participation level by anes-
thesiology groups in the past has allowed
the MGMA to produce an anesthesia-
specific cost report in conjunction with
the MGMA Anesthesia Administration
Assembly (AAA). If participation levels
remain high, the Cost Survey for Anesthe-
sia and Pain Management Practices will be
available in 2009.
Data from your practice’s billing and
accounting systems will be needed to
complete the cost survey. Practices that
have outsourced billing, accounting, and
management should ask for the assistance
of their service provider to complete the
survey. A few practice management
systems produce special reports tailored
to MGMA survey requirements. If there
are any questions about completing the
survey, the MGMA staff is willing to assist
via telephone or email.
The Cost Survey is available in PDF,
as well as Excel-based, and online web-
based versions. The online web-based
version is preferred because of the exten-
sive real-time editing features and because
your data is input directly to the MGMA
resulting in greater accuracy. You can
complete the web-based cost survey in
multiple sessions and from any location
with internet access. Online help is avail-
able while you are answering the survey
questions. Data from your prior survey is
also available online.
Since this article was written, the
May 2 deadline has passed. If you have
completed your questionnaire, you will
receive your Cost Survey report by mail.
If not, you may order a copy of the report
from the MGMA.

What is your Cost per Anesthetizing Location?
so too, anesthesia practice managers
should remember that economics is not
a discipline that respects one’s wishes.
Unreasonable commitments ultimately
come to haunt not only the people who
made them, but the practice that has to
make good on them. Successful practices
have learned that the careful monitoring
and management of three distinct
phenomena can make all the difference.
The first is revenue maximization and
a detailed appreciation of all the factors
that are responsible for the group’s
cashflow, from managed care contracting
to revenue cycle management.The second
is expense management and a clear set of
criteria and benchmarks for determining
just how generous the practice can really
afford to be to its employees. The third,
and most critical, is the arcane science of
cost-accounting applied to the even more
obscure management of a competitive
cost structure. Knowing whether the
practice is appropriately staffed and what
services it can reasonably be expected to
provide may seem complicated; actually
it is not. Like so many disciplines, this is
just a matter of understanding a few key
principles and knowing how to apply
them judiciously.
It is the rare anesthesiologist or
CRNA who does not know that he or she
should be paid for the services performed;
unfortunately, too few can actually
establish this objectively based on the
practice’spayormixandproductionlevels.
A mastery of revenue cycle management
necessarily involves an understanding
and mastery of accounts receivable
performance metrics. Any serious effort
to benchmark a practice must begin with
a careful review of the factors that create
value. No serious negotiation with a
hospital can ignore the need for complete
and reliable management information
such as unit production, payor mix, and
accounts receivable metrics such as Days
in AR (DAR) and bad debt percentages.
The same is true of expense
management. There is no substitute
for regular financial statements and an
appreciation of the insidious chasm
between provider expectations and the
practice’s financial realities. It is curious
that so many anesthesia practices eschew
the notion of budget and yet, in ignoring
the need to establish reasonable levels of
incomeandexpense,theyleavethemselves
especially vulnerable to the vagaries of
the market. Intuitively, all anesthesia
providers know that one cannot manage
what one does not measure, but somehow
the application of this important business
concept gets lost in the management of
the practice as a whole.
It is not enough, though, to have
a clear understanding of the revenue
cycle, nor is it enough to manage
expenses aggressively; these are relative
management tools and can be very
misleading without an objective
reconciliation to market realities. In the
atomistic world of anesthesia this can be
especially intimidating. Every practice
wants to believe that its situation is
unique and that compensation should be
commensurate with the specific services
provided in the local market. While there
is always some element of truth to this
view, its relevance is much less significant
than most are willing to admit.
Today’s successful practices
understand and appreciate the concept
of normalized productivity metrics.
Consider the problem. Two practices
provide similar coverage. One relies
exclusively on physicians and the other
on a leveraged care team model. Since
their cost structures are so different, how
does one determine what is reasonable,
especially when it comes to asking for
financial support from a hospital? When
faced with such a problem, a growing
number of consultants are now turning
to a simple calculation that yields the net
cost per anesthetizing location.
Continued from page 1
Table 1

Understanding this notion requires
a disciplined view of the practice.
For purposes of this discussion an
anesthetizing location is defined as an
actual or virtual location that requires
dedicated anesthesia staffing for part
or all of a 24 hour period. This will
include operating rooms, delivery suites,
and dedicated coverage for non-OR
anesthesia (NORA). Consider Table 1
on page 4, which represents the coverage
requirements of a hypothetical practice.
You will note that coverage is simply
defined as the number of locations
that must be staffed each day of the
week. For purposes of highlighting the
methodology, we have used an example
in which the number of rooms varies by
day of the week. Some will argue that one
must also consider how long each room
will run and how many hours of coverage
are necessary for each location. This can
be a relevant enhancement to the model,
but it may also complicate the analysis
needlessly, especially when the objective
is to use this information for an objective
and meaningful comparison to other
practices.
Applying this coverage map to our
analysis requires multiplying each of the
coverage tallies by the number of days
associated with that day. In other words
if there are four non-holiday Mondays in
January then the total Monday coverage
days equals 48 (12 * 4). Table 2 above
provides a summary tally of the total
location days the practice must cover
in 2008, a leap year. While it is useful to
know how to perform this calculation,
the key to the analysis is to know the
total (3,280 Hospital Location Days) for
it is this number that ultimately drives
all subsequent cost calculations and
benchmark comparisons.
Based on the determination of
total annual anesthetizing locations, it
is possible to calculate both the revenue
metric and the cost metric, and ultimately
to work through various scenarios to
balance the two.
The objective of the revenue metric
calculations is the establishment of the
revenue per location day. This number is
relatively easy to identify when one looks
back in time, because actual net collections
can be divided by actual coverage tallies.
Doing the calculation prospectively
can be a little trickier because it will
require a reasonable estimate of expected
collections levels. This subtle challenge
notwithstanding, let us suppose that we
agree the practice will collect $5,000,000
afterrefunds.Theresultwouldbearevenue
per location day of $1,692.00, which
according to the 2007 MGMA Cost survey,
is close to the average cost per location day
of those practices that contributed.
By most staffing models, this level of
coverage would require at least 15 FTE
(Full-time Equivalent) anesthesiologists
in an MD only practice. Obviously,
actual staffing will vary based on a
variety of factors, but this is intended as
a representative example for purposes of
establishing a point of comparison for one
staffing model versus another. Based on
this assumption, the cost per location day
is considerably higher than the revenue,
which is an all too common phenomenon
across the country and the reason why
so many practices must seek financial
support to maintain coverage levels.
Continued on page 6
Revenue per Location
Day Calculation
Annual Case Volume 12,000
ASA Unit Production 150,000
Yield per ASA Unit $37.00
Expected Revenue $5,550,000
Annual Location Days 3,280
Actual Revenue/
Location Day $1,692
Table 2
Table 3

Many an anesthesia practice will get
this far in their calculation of the need
for financial support and think they are
ready to present their subsidy request to
administration. Nothing could be more
perilous. Establishing the level of support
to be requested is only the first step. The
calculations presented thus far only speak
to the economics of coverage as viewed
from the anesthesia perspective. Failure
to assess the potential request from the
hospital’s perspective is sure to have
serious tactical, not to mention, financial
repercussions.
Hospital administrators have two
perspectives when it comes to hospital-
based physicians. They always start
by asking what the current terms of
the contract are and why they need
to change. If the discussion survives a
logical review of market factors and new
coverage requests, then it moves to the
second big question: why can’t the group
accommodate the hospital’s requirements
by modifying the way it provides the
services? Administrators have come to
believe in the notion of care-extenders,
and often push back on the practice to
“simply hire more CRNAs.”It has become
almost a matter of course that hospital
administrators will ask for an analysis
of a more leveraged care team model. If
the group does not do its homework and
prepare the necessary analysis prior to the
first meeting, the results are sure to be
disappointing for all parties involved.
The fact is that well-managed
practices should be performing the
following assessments on a periodic
basis. Think of mastering these financial
tools as practicing for the big game. The
more comfortable one gets with the basic
concepts, the more reliable the analysis
will be and the more adeptly it can be
applied to a variety of practice scenarios,
fromsimplecoveragedecisionstohospital
negotiations.
In the example in Table 5, a total
annual cost per CRNA of $175,000 is
used. This is actually somewhat below
market, and is used here simply to
highlight the argument and beliefs of
hospital administrators, that it is the cost
of the physicians that is creating the need
for the subsidy. Two points of comparison
are provided according to an assessment
of reasonably equivalent staffing ratios
based on a determination of FTE
providers per 10,000 units billed. Option
A simply highlights the financial impact
of a nominal change in staffing model,
while option B demonstrates the potential
impact of a wholesale shift in the model.
The savings of such a restructuring are
significant. Of course, such an analysis
fails to address the implications of actually
executing such a transformation, not to
mention the challenge of hiring so many
new providers.
Why is it becoming ever harder for
anesthesia practices to negotiate the levels
Staffing Cost Caculation
What is your Cost per Anesthetizing Location?
Days of coverage 3,280
Days worked 226
FTE Anesthesiologists 15
Total cost at $420,000
per physician per year $6,300,000
Annual Location Days 3,280
Actual Cost/
Location Day $1,921
Option A: Nominal Leverage using CRNAs
# Comp & Benefits Total Cost
Number of Physicians 14 $420,000 $5,800,000
Number of CRNAs 2 $175,000 $350,000
Total Team Cost $6,230,000
Location Days 3,280 $1,899.39
Option B: Significant Leverage using CRNAs
Number of CRNAs 14 $175,000 $2,450,000
Table 4
Current Model: Physician only
Number of CRNAs 0 $175,000 $0
Table 5

of stipend that many were obtaining so
consistently even a couple of years ago?
The answer has to do with three words
that should be a source of great concern
to anesthesia practice administrators: fair
market value. This is not a consideration
when a hospital employs the CRNAs.
Hospitals can pay their own employees
whatever they want to. They are also free
to hire as many individual providers as
their budgets permit.
The minute the cost of anesthesia
services involves a payment to another
entity, however, there is an entirely
different set of guidelines and limitations.
Fair Market Value (FMV) assessments
are essential to compliance with Stark,
antikickback, and in some cases even
the antitrust laws. Administrators and
their legal counsel talk about such
determinations as if they represented
an objective science. The reality is
much closer to the appraisal of a house
where the outcome is always influenced
significantly by the agent performing
the analysis. Anesthesia practices should
understand that FMV is the hospital’s
ultimate refuge and protection from the
anesthesia subsidy request.
This is exactly why the notion of anes-
thetizing location is so critical to the future
of today’sanesthesiapractices.Hospitalsti-
pends fall into three main categories: those
based on a negotiated annual amount,
those based on staffing requirements, and
those based on coverage requirements.
There is a variation on the second that
will involve the identification of loss leader
services such as cardiac or OB anesthesia.
When it comes to negotiating leverage,
the real opportunity for the typical prac-
tice lies with arrangements that provide
an alignment of incentives between the
hospital’s desire to maximize availability
for surgeons to book cases and the cost of
providing the necessary anesthesia provid-
ers to get the work done. This is where the
location rate card can be played so effec-
tively. Doing so, however, requires care-
ful planning and preparation. As with the
acquisition of many new skills and tech-
niques, the first few times you use them
you immediately come to understand how
you could have used them differently and
more effectively.
An understanding and appreciation
of the value of anesthetizing location may
not solve all the financial challenges of an
anesthesia practice. In fact, it may reveal
challenges and issues that practice had
never even considered. What the use of
such calculations does provide, however,
is a form of communication that puts
anesthesiapracticesmoreonalevelplaying
field with hospital administrations,a form
of common currency that allows for more
effective discussion of the real challenges
facing both the anesthesia practice and
the hospital. If used logically and as an
educational tool, such an approach will
definitely change the tenor and tone of
the discussion between the group and
its hospital. This is not a panacea, but a
tool that must be used carefully and with
discipline. As anyone who has used the
tool can attest, though, it is probably one
of the most useful and innovative tools
today’s anesthesia practices has.Whatever
your situation it is hard to ignore the
potential of such an opportunity.

The Washington Area Anesthesiology
Administrators Group:
ABC Organizes the Kickoff Meeting of the WAAAG
By Karin Bierstein, JD, MPH
Who are some of the people most
likely to have solutions to problems such
as an unintelligible new payer directive
or the spread of rumors among local an-
esthesiologists that Medicare is going to
stop paying for procedures performed in
the outpatient setting? Officers and man-
agers of other groups who have already
addressed an issue that has just surfaced
in their geographic area are often an ex-
cellent resource.
Recognizing the value of a local
network to foster the exchange of
information (but not potentially anti-
competitive information such as fees!)
among anesthesiology group leaders,
ABC brought together twenty physicians
and administrators for a half-day meeting
in a Washington, D.C. hotel on April 1,
2008. Our model for this venture was the
Tristate Anesthesia Administrators Group
or “TAAG” that has been convening rep-
resentatives of practices in Pennsylvania,
New Jersey, Maryland, and more recently
Delaware for a number of years. Stephen
Comess, a recent TAAG past president,
joined us to explain the achievements and
operations of that group.
Our guests included not just ABC cli-
ents, but also others who responded to an
open invitation posted on the listserv of
the Medical Group Management Associa-
tion’s Anesthesia Administration Assembly
(MGMA AAA). The first speaker at the
WAAAG meeting was the attorney whose
expertise in anesthesia issues is second to
none: Judith Jurin Semo, Esq., who prac-
tices in the Washington area – and across
the country. Ms. Semo provided a fresh
perspective on “When the Hospital No
Longer Wants to Pay: Contract Nego-
tiations.” If you feel that your hospital is
demanding far more than it ever did in the
past, you are not alone.
A second attorney, Catherine D. Ber-
tram, Esq. (the WAAAG meeting took
place in Washington, D.C., where some
say that every 20th person on the street
is a lawyer) spoke next. Ms. Bertram is
a trial lawyer and former hospital risk
management counsel who demonstrated
many of the skills with which she keeps
the attention of juries as she explained
what anesthesiologists should do to make
sure that they never meet her across the
table at a deposition, let alone in the
courtroom. Note: participants raised
the question whether anesthesiologists
should personally discuss the risks of
anesthesia and personally obtain the pa-
tient’s informed consent. This is an issue
that continues to arouse debate in the
specialty; Ms. Bertram, however, was as
unequivocal as every other lawyer you
have heard on the vulnerability of the an-
esthesiologist who delegates this function
to a non-physician.
We were fortunate enough to have a
third speaker, Richard Rauh, Executive
Director of Southeast Anesthesiology
Consultants,P.A.andSoutheastPainMan-
agement, PLLC in Charlotte, NC. Mr.
Rauh described the many components of
the highly successful pain practice he has
helped his group build.
ABC’s major objective was met
when Denise A. Lascar, RN, MBA, MHA,
President of the Center for Ambulatory
Surgery, Inc. in Washington, DC, an ABC
client and an active member of the AAA,
volunteered to become the first president
of the WAAAG and to organize its second
meeting. It was most satisfying to the
ABC staff who organized the kickoff to
see the enthusiasm of the participants for
an ongoing local best-practices forum.
Readers who would like to make sure
that they are on the WAAAG mailing list
should send their contact information via
email to meetings@anesthesiallc.com.
Readers in “the other Washington”
who would like to attend a similar event
should note that ABC and AAI1
are
planningtoconvenethefirstmeetingofthe
SWAAG (State of Washington Anesthesia
Administrators Group) in Seattle on
June 4, 2008. If you are interested in
attending, please send an email, including
your contact information, to meetings@
anesthesiallc.com.
ABC CEO Tony Mira is a strong be-
liever in the value to our clients, and to
others, of regional networking. Plans are
in the works for us to help launch local
interest groups in Michigan, Wisconsin
and North Carolina. We encourage po-
tential speakers and other participants to
contact us.
1
Anesthesia Business Consultants, LLC
(ABC) and Anesthesiologists Associated, Inc.
(AAI) announced January 23rd the completion
of a business combination.

Continued on page 11
Anesthesia Group (Un)Governance
By Mark F.Weiss, J.D.
Democracy is fine for government; it
just doesn’t work for anesthesia groups of
more than a few members, at least not on
any level past the election of a leader.
You may have heard the expression,
“money likes speed,” the notion being
that you have to move quickly to take ad-
vantage of a profitable opportunity. The
fact is that success in business, in general,
requires the ability to quickly analyze a
situation and come to a decision.
Anesthesia groups face many chal-
lenges in the marketplace. Many of those
challenges are external, such as the de-
crepit level of payment from Medicare
and the overall commoditization of the
profession. It’s simply stupid to further
hinder your group’s business by making it
difficult or even impossible to make busi-
ness decisions on a timely basis. Yet this is
what many groups do through their pro-
cesses of participatory decision making.
Following a speech at a national con-
ference, an anesthesiologist approached
me. He told me that his group faced
major challenges in terms of competition,
which resulted in lowered per-physician
income. However, the group’s board had
been unable, for over a year, to come to a
decision about what to do. The point had
come that some members were threaten-
ing to leave for what they perceived as
better opportunities.
I asked him how many anesthesi-
ologists there were in the group, and he
responded,“Thirty-six.” I then asked how
many of the thirty-six were shareholders,
and he responded, “Thirty-six.” Finally, I
asked how many sat on the board of di-
rectors, and he responded,“Thirty-six.”
Is there any wonder why they couldn’t
come to a decision? Can you imagine how
long a board meeting must last?
The unfortunate fact is that this poor
group is by no means an anomaly. I don’t
mean to profess that I’ve conducted a
scientific study, but over the course of
decades, I’ve come across far too many
anesthesia groups that have painted
themselves into a corner in terms of being
able to make decisions because they allow
far too many to participate in the decision
making process.
Perhaps this results from the collegial
nature of most physicians. I often hear
from clients that everyone on the “team”
is equal because everyone is an anesthesi-
ologist. That philosophy doesn’t work for
baseball teams – and it doesn’t work for
anesthesia groups, either.
I recently concluded the negotiation
of a two-year exclusive contract relation-
ship in which the hospital is paying my
client group a significant seven figure
annual stipend. Just prior to the date
set for signing, the hospital offered to
increase the term of the contract by an
additional year. My client’s response was
that it would require a shareholder vote
and, due to vacations, a quorum would
not be available until sometime at the end
of the following month. The hospital did
not want to wait.
There’s no way to know for two years
whether this group’s default position will
result in a better or worse future for the
group. What is certain is that its structure
left it unable to exercise any leadership in
attempting to determine its own future.
Even a hastily made decision is better than
simply permitting a third party to make a
decision based on its best interests.
Whether your group is organized as
a corporation or as a partnership, it is es-
sential that you adopt a corporate-style
structure for decision making. This in-

Succeeding At Negotiations
Through Preparatory Work
And Psychological Operations
By Mark F.Weiss, J.D.
Advisory Law Group, A Professional Corporation
Los Angeles, CA • Santa Barbara, CA
Popular books on negotiation are
nearly useless in respect of negotiating an
exclusive anesthesia contract. They con-
fuse negotiation with bargaining, focus
on transactions and not on relationships,
and, perhaps worst of all, they portray
negotiation as a series of back and forth
proposals and counterproposals.
True negotiation in respect of an ex-
clusive contract is an extensive process
that is wedded to, and cannot be sepa-
rated from, a larger strategic vision and a
wide set of tactical tools. I refer to this
process as the Exclusive Contracting
ContinuumTM
.
Negotiation does not involve a time
line, although timing is very important.
The time to “start” negotiations on an ex-
clusive contract is not when the RFP hits
your desk, it’s not when the CEO delivers
a draft of the proposed document, and it’s
not some magic three,or even six,months
prior to the end of your current contract’s
term. Rather, the time to being negoti-
ating is . . . well, in the paradigm I urge
you adopt, it’s actually already begun. My
clients understand that the day to “begin”
negotiating their next exclusive contract
is the day they execute their present ex-
clusive contract.
As opposed to a timeline paradigm,
the Exclusive Contracting Continuum is
diagrammed in simple form as a recur-
ring cycle of subprocesses; more fully,
it’s diagrammed in the form of an atom,
with each of the subprocesses revolving
around the nucleus.
Although there is a certain order to
the commencement of some of the el-
ements in the initial adoption of the
Continuum, once begun, they operate
continuously. Among the many elements
of the Exclusive Contracting Continuum
are the following subprocesses:
If a group’s members’ interests aren’t
aligned with the group, all of its other ef-
forts expended in the Continuum process
may be for naught. The Group Align-
mentTM
subprocess involves an analysis,
and potential realignment, of the group’s
personnel and of incentives and restric-
tions, both monetary and non-monetary.
Deal points, which are developed
through a specific subprocess, do not
exist in a vacuum – they exist within a
framework. Without intervention, the
framework is destined to be that of the
hospital. Accordingly, we must devote
significant efforts to framing the issues
in a group-favorable manner well in
advance; many of the elements of the
Continuum provide the tools to dissemi-
nate the message.
The subprocess known as The
KnowledgeTM
is an intelligence gathering
operation. It’s aimed at gathering as much
in-depth information on the facility you
are targeting and on the individuals who
are in a position to influence the facility’s
decision. This process is also deployed
toward potential competitors.
The ultimate purposes of The Knowl-
edge process are to influence the behavior
of third parties in favor of the group, and
to alter their perceptions of it. This is
accomplished though a series force multi-
pliers known militarily as “psychological
operations.” These include profiling, with
the goal of deducing how the subject will
think, behave, and act in similar circum-
The
Knowledge™
Disinformation
Data Spin™
Shadowing
the
influencers™
Focus on
the Future™
The
Group
Alignment™

Coding Corner
stances. The results of profiling are used
as a guide for tactics deployed against the
profiled individuals. They are also used
in deploying created circumstances, both
real and verisimilitudinous, likely to drive
the subject’s behavior in the manner most
favorable to achieving our goals. Finally,
profiling results are valuable in planning
situations in which the predicted behav-
ior itself can be used to create a pitfall.
The subprocess of developing com-
munity awareness uses the results of The
Knowledge to accomplish two objectives:
Thefirstistocreatedirectbenefitfromtheir
performance – in other words, to do good
while you are doing well. The second is to
manufacture situations that can be publi-
cized in order to sway broader opinion.
In order to publicize the group’s ac-
tivities, there is a coordinated Publicity
PushTM
. Putting the Publicity Push into
context, participation in events that de-
velop community awareness brings a
limited, but highly focused, community
consciousness. The purpose of the Pub-
licity Push is to leverage off of the group’s
community and other activities to include
a larger audience, one that will directly or
indirectly be of benefit to the group.
Just as the creation of community
awareness and the related Publicity Push
seek to transmit truthful, yet spun, in-
formation that is attuned to its intended
audience as a result of profiling, a simi-
lar process using disinformation can
be employed. “Disinformation” in this
context is misinformation that is delib-
erately disseminated in order to influence
or confuse.
As briefly outlined above, negotiation
is a continual process, not a 1-2-3 series
of steps arranged upon a timeline. Proper
preparation for the “face to face” stage of
negotiation requires a long term commit-
ment to developing information and to
employing it. This effort is best viewed
as a series of interlocking processes de-
signed to maximize your outcome. The
processes I present today are among the
many processes that comprise the com-
plete Contracting Continuum.
volves a basic level of democracy in terms
of electing a board, which in turn elects a
leader. Small groups may dispense with
the notion of a board.
Simply adopting a corporate-style
structure for decision making is not
enough. In order to be effective in terms
of business decision making, the rules
pertaining to power sharing among the
levels must err on the side of allocating
too much power upward in the chain.
At the basic level of shareholder or
partner, group members should be en-
titled to vote for board members and on
those major events that state law reserves
to equity owners, such as dissolution of
the group. The fewer other voting rights,
the better.
If the group has a board, its purpose
should be limited to major policy deci-
sion making and to electing the president
or managing partner. The board should
not be empowered to make day to day
business decisions or to override the de-
cisions of the group’s leader.
That leaves the group’s leader free to
make decisions.
Understand that this is not meant to
belittle the “we’re all doctors” mentality.
Of course you are. You are all human
beings, too. It’s just that you all can’t be
leaders or there will be no leadership.
Sorry, it’s tough love.
ABOUT MARK F. WEISS
Mark F. Weiss is a nationally recog-
nized expert, and a frequent author
and speaker, on the business and
legal issues affecting anesthesiolo-
gists and anesthesia groups. Mr.
Weiss holds an appointment as
Clinical Assistant Professor of An-
esthesiology at USC’s Keck School
of Medicine, where he developed
and teaches a lecture series course
on the business and legal issues
affecting anesthesiologists. He
practices law with Advisory Law
Group, A Professional Corpora-
tion, with offices in Los Angeles and
Santa Barbara, California.
Anesthesia Group (Un)Governance
(Reprinted with permission)
Medicare NowValues CPT®
Code 00797 at the Correct
Level – 11 Base Units
When the 2008 Medicare Fee Schedule
first appeared, the American Society of Anes-
thesiologists (ASA) contacted the Center for
Medicare and Medicaid Services (CMS) to
report an error posted on the CMS website.
The error incorrectly listed the base units for
CPT Code 00797, Anesthesia for intraperito-
neal procedures in upper abdomen including
laparoscopy gastric restrictive procedure for
morbid obesity. The correct base unit value,
11 units, is now listed on the CMS website at
hhtp://www.cms.hhs.gov/center/anesth.asp.
ASA was informed by CMS that Medi-
care carriers received the correct base unit
information printed in the HCPCS file in late
2007. Until recently Medicare therefore pro-
cessed all 2008 claims for 00797 at the 11 base
unit value rather than the incorrect posting
of 8 base units. ASA noted that some private
payers may have used the incorrectly-posted
base unit value from the CMS website.
On behalf of our clients, we have re-
viewed the CPT code 00797 payments paid to
our clients and we will contact any third party
payers to ensure proper reimbursement. For
others, we highly recommend sharing the
corrected web posting with your third party
payers so you may be reimbursed properly.

Oig Workplan 2008:
Interventional Pain Procedures
Included
Abby Pendleton, Esq.
Jessica L. Gustafson, Esq.
Wachler & Associates, P.C.
On October 1, 2007, the Department
of Health and Human Services (HHS)
Office of Inspector General (OIG) issued
its 2008 annual Work Plan, which out-
lined the key focus areas and projects the
OIG intends to pursue during the 2008
fiscal year (FY 2008). The OIG Work Plan
is available in its entirety from the OIG
website. 1
Approximately80percentof theOIG’s
resources are devoted to projects within
the Medicare and Medicaid programs.
These projects include audits, evalua-
tions, investigations, and legal activities.
Although the 2008 Work Plan outlines the
OIG’s intended areas of activity for the
fiscal year ahead, the OIG also has noted
that work planning is a dynamic process
that continues after the publication of its
annual Work Plan. Thus, after analyz-
ing current events and emerging issues as
they arise, the OIG may add new activities
or cancel or delay planned activities, as it
deems appropriate.
Of particular importance to the pain
management community, the OIG an-
nouncedthatoneofitsplannedfocusareas
for2008wouldbe“MedicarePaymentsfor
Interventional Pain Management Proce-
dures”. The OIG also included “Medicare
“Incident to” Services” as a planned focus
area. Given this information, pain man-
agement physicians should be prepared to
face increased scrutiny with regard to bill-
ing and documentation practices.
Specifically with respect to pain man-
agement, the OIG has stated its intentions
to do the following in FY 2008:
We will review Medicare payments
for interventional pain management
procedures. Section 1862(a)(1)(A)
of the Social Security Act provides
that Medicare will pay for services
only if they are medically necessary.
Interventional pain management
procedures consist of minimally in-
vasive procedures, such as needle
placement of drugs in targeted areas,
ablation of targeted nerves, and some
surgical techniques. Many clini-
cians believe that these procedures
are useful in diagnosing and treat-
ing chronic, localized pain that does
not respond well to other treatments.
Interventional pain management is
a relatively new and growing medi-
cal specialty. In 2005, Medicare paid
nearly $2 billion for these procedures.
We will determine the appropri-
ateness of Medicare payments for
interventional pain management
procedures and assess the oversight
of these procedures.
The OIG also stated its intention to
review the medical necessity, documen-
tation, and quality of care for “incident
to” services. In general, the Medicare
“incident to” rules allow claims by non-
physicians to be submitted under the
physician’s provider number if certain
specified requirements are met. Nota-
As part of our desire to keep both clients and
readers up to date, the Communiqué has been
printing compliance information since its
inception. In the Compliance Corner, we will
now formally keep you abreast of the various
compliance issues and/or pick out a topic that
would be of interest to most of our readers.

bly, the claim will be paid at 100 percent
of the Medicare physician fee schedule
even though the services were in fact
furnished by auxiliary personnel. In gen-
eral, in order to bill such services, they
have to meet particular requirements.
For example, services may be covered as
“incident to” services if they are: (1) fur-
nished in a non-institutional setting (e.g.,
a physician’s office) to non-institutional
patients; (2) an integral, though inciden-
tal, part of the service of a physician in
the course of diagnosis or treatment of an
injury or illness; (3) commonly furnished
without charge or included in the bill of
a physician; (4) of a type that are com-
monly furnished in the office or clinic of a
physician; (5) furnished under the direct
supervision of the physician (i.e., in the
office suite); and (6) furnished by person-
nel who are employed or contracted by
the physician (i.e., the physician/group
must pay the cost of the individual).
Physical therapy services also have addi-
tional requirements/limitations relative
to the types of individuals who may per-
form the physical therapy services.
Given the OIG’s pronouncement
regarding its intention to review inter-
ventional pain procedures and “incident
to services” (which are common in some
pain practices), pain physicians are well
advised to continue and pursue proac-
tive compliance measures. There are a
number of action steps that a physician
can undertake to become more informed
and to reduce compliance exposure in
these areas including, but not limited to:
1. Obtain,review,and follow,if appli-
cable, the local Medicare Carrier’s
policy or policies on pain proce-
dures. These policies often contain
critical information regarding
documentation and medical ne-
cessity requirements. Physicians
are responsible under the law for
knowing the information in these
policies.
2. Obtain, review, and follow policies
issued by third party payors ad-
dressing these services. Physicians
must remember that compliance
is not specific to Medicare and
Medicaid (i.e., failure to follow the
rules of other payors can also lead
to exposure under various state
and federal laws).
3. Obtain and review the Medicare
incident to requirements to ensure
compliance. For example, physi-
cians must be aware and comply
with the on-site supervision re-
quirement. Some physicians
mistakenly believe that complying
with less stringent public health
code supervision requirements
is sufficient for billing purposes.
This simple mistake can create false
claims exposure for a physician.
4. Establish internal documentation
criteria for all members of the
group to follow with regard to ser-
vices and procedures.
5. Educate all members of the group
as to the importance of documen-
tation and other requirements
including medical necessity.
BIOGRAPHIES
Abby Pendleton is a partner and Jes-
sica Gustafson is an associate with
the healthcare law firm of Wachler &
Associates, P.C. The firm represents
healthcare entities and providers
with their healthcare legal needs. Ms.
PendletonandMs.Gustafsonspecial-
ize in a number of areas, including
but not limited to: Medicare and
other third party payor audit defense
and appeals; compliance; transac-
tional and corporate matters; fraud
and abuse analysis; reimbursement
and contracting matters; licensure,
staff privilege and third party payor
de-participation matters; healthcare
fraud defense; and HIPAA privacy
and security compliance.
1
OIG Work Plan, Fiscal Year 2008, available
at http://www.oig.hhs.gov/publications/docs/
workplan/2008/Work_Plan_FY_2008.pdf
(last accessed February 24, 2008.

OR Succession Planning, Change
Management, and Leadership
Development
By Jerry Ippolito
President OR Efficiencies, LLC – Naples, FL
Last night’s
party was great! I
can’t think of when
we all had such a
wonderful time to-
gether. The OR staff,
surgeons, anesthe-
siologists, residents
and even adminis-
tration were in full
attendance. All of the day’s issues were
put aside as we celebrated Mary’s retire-
ment. Where have all of these years gone?
Mary had been our medical center’s Di-
rector of Surgical Services for nearly three
decades – she was here when I was a med
student and bailed me out so many times
during my anesthesia residency. She was
tough but well respected for her ability to
keep our fifteen rooms running like a well
tuned race-car. However this morning
the dreaded hangover set in – no, not the
one from the extra martini; the one of the
reality that the Director’s office is dark.
We’ve heard nothing regarding Mary’s re-
placement and the Chief Nursing Officer
told me that there are no qualified candi-
dates with interest in our community. The
most qualified candidate turned down the
opportunity because the spouse wouldn’t
be able to find appropriate employment.
Several staffing agencies have been ap-
proached but qualified interim managers
are not available for at least three months.
One of the CNO’s thoughts is to use this
void of leadership as an opportunity to
bring in a consultant to assess whether we
are doing things as best possible – that’s
not a bad idea, but who is going to run the
OR on a daily basis? I told the CEO that
as Chief of Anesthesiology I’d step up to
the plate and do whatever I can – he rec-
ognizes that it won’t be easy for me as the
Chief of Surgery is a talented surgeon but
an ineffective leader of his peers. I really
don’t want to run the OR; I prefer teach-
ing the anesthesia residents. What has
happened here? Mary’s been planning
this retirement for eighteen months and
here we are – an ocean liner at full steam
ahead and there’s no captain on board.
Man the life-boats !!
The above scenario is not as melodra-
matic as it seems and does not represent
any one hospital. Although what I’ve
presented in this scenario is fiction, it is
happening in real time, every day, at many
hospitalsacrossthenation. Asevereshort-
age of perioperative services leadership is
increasingly evident in the nation’s surgi-
cal programs. According to the American
Association of Operating Room Nurses
(AORN), the average age of the OR nurse
is in excess of 42 years and increasing.
Typically even the most accomplished of
individuals require at least ten to fifteen
years experience as a Director of Surgical
Services to be optimally effective in pro-
grams with high case volumes; even more
experience is required in highly political
environments. Accomplished surgery
leaders have been vacating the field for re-
tirement or career opportunities in other
realms of health care or industry in gen-
eral. The critical shortage of incoming
nurses, coupled with the lack of focused
identification of leadership potential, skill
development, and mentoring, has created
a serious shortage of surgery program
leaders. While this void of leadership is
most felt among directors of surgical ser-
vices, it is not exclusively limited to that
population. A void of effective leadership
is frequently experienced among a hospi-
tal’s medical staff (e.g. Chief of Surgery;
Chief of Anesthesiology, etc.)
Directors of Surgical Services typi-
cally rise through the staff ranks as
talented OR nurses. Medical staff chiefs
of service are typically individuals who
are recognized as excellent physicians;
Jerry Ippolito

or well liked among peers; or recognized
by peers as not wanting to “rock-their-
boat”. Individuals with superior clinical
skills, whether nurse or physician, are too
frequently presumed to possess a similar
ability to perform as managers despite
lack of any planning and preparation for
these new responsibilities.
The challenges of today’s complex
surgical services programs dictate the
need for uninterrupted and proactive
management to:
• Provide dynamic, stable leadership
across all components of periop-
erative services;
• Facilitate day-to-day communica-
tion among key stakeholders;
• Identify opportunities to imple-
ment new programs and improved
processes enhancing patient care,
optimizing physician productivity,
and promoting staff retention;
• Assure programs’ marketability to
staff, surgeons, anesthesiologists
and anesthetists;
• Maintain programs’ financial
viability.
Author John Maxwell writes that an
organization can only grow as far as the
leadership potential of its top leaders.
To keep ahead of the competition, com-
panies / hospitals / medical groups must
continually make changes. Healthcare
executives want their hospitals and surgi-
cal programs to rise to the next level, and
to do so the administrative team, pro-
gram directors, and physician leadership
(surgical and anesthesiology department
chairs) must be capable of supporting
and sustaining necessary change. A hos-
pital CEO (or even anesthesiology group
practice president) may have the vision
of where they want their organization to
go, but that does not necessarily mean
the leadership team possesses the skills
to lead the organization along the path
to success. Consultants can be engaged
to identify opportunities for making pro-
gram change and assist in implementing
successful change. However, if a hospi-
tal’s leadership team is not capable of
sustaining change, then programs will
regress after the consultant leaves, regard-
less of the capabilities and successes of the
consultant. While the consultant is guid-
ing change, implementation projects are
generally filled with staff and physician
energy and excitement. Unfortunately,
without an effective leadership team to
maintain program focus and determine
priorities, it does not take long for ef-
fectively implemented change to become
derailed by higher priorities or a lack of
acceptance from others after the consul-
tant departs. The cost of changes that fail
(or then the regression of success) goes
far beyond financial cost or foregone rev-
enue. When changes fail and programs
regress in organizations, employees and
physicians begin to lose trust in the lead-
ership of the organization. They become
frustrated, cynical, and begin to give up.
Employees and physicians often turn
into chronic complainers, making future
change efforts even less likely to succeed.
Most hospitals have medical staff de-
velopment plans that are built on practice
succession planning to assure continu-
ity of medical staff services based at the
hospital. Too frequently the need for
managerial succession planning (par-
ticularly within perioperative services)
goes unrecognized. There is a need for
proactive identification of individuals
from within the ranks (nursing; medical
staff; management; etc) who can be men-
tored to develop their skills in inspiring
excellence in themselves, their peers, staff,
and their organizations (in addition to
the traditional organizational and finan-
cial skills). Leaders need to be developed
to support healthier organizations that
produce higher levels of results. Leaders
must be developed to act more like coach-
es within organizations. Performance
and morale improves remarkably when
leaders possess the ability to motivate and
inspire employees and peers just like some
of the great sports coaches. When an or-
ganizational culture is established and an
atmosphere is developed where individu-
als are encouraged and nurtured to thrive
the following typically results:
• Improved recruitment and reten-
tion of highly skilled staff;
• Continuity of effective
management;
• Improved work processes and re-
duced problems;
• Improved relationships with em-
ployees, bosses, and peers;
• Development of concrete strate-
gies to achieve their goals;
• Ability to delegate tasks and spend
more time managing people;
• A sense of energy and passion for
what people do;
• Improved OR productivity;
• Improved case start times;
• Decreased turnaround times;
• Decreased total case times;
• And last but not least –
IMPROVED OR EFFICIENCIES!!

Professional Events
Date Event Location Contact Info
Apr. 30-May 4, 2008 Society of Obstetric Anesthesia and
Perinatology Annual Meeting
Renaissance Chicago Hotel,
Chicago, IL
www.soap.org
May 1-4, 2008 Society for Ambulatory Anesthesia Annual
Meeting
Loews Miami Beach Hotel,
Miami Beach, FL
www.sambahq.org
May 15-18, 2008 Association of University Anesthesiologists
55th Annual Meeting
Washington Duke Inn & Golf Club,
Durham, NC
www.auahq.org/annualmtg.html
May 17-18, 2008 MGMA Pain Management Preconference Philadelphia Marriott Downtown,
Philadelphia, PA
www.mgma.com
May 18-21, 2008 MGMA AAA Annual Conference Philadelphia Marriott Downtown,
Philadelphia, PA
www.mgma.com
May 30- Jun 1, 2008 CSA/UCSD Annual Meeting & Clinical
Anesthesia Update
Hilton Los Angeles/Universal City,
Los Angeles, CA
www.csahq.org
Jun. 18-22, 2008 Society of Cardiovascular Anesthesiologists
Annual Meeting & Workshops
Vancouver Convention & Exhibit
Center, Vancouver, BC, Canada
www.scahq.org
Aug. 9-13, 2008 American Association of Nurse Anesthetists
Annual Meeting
Minneapolis Convention Center,
Minneapolis, MN
www.aana.com
Sep. 11-14, 2008 New England Society of Anesthesiologists
Annual Meeting
Marriott Hotel on the Wharf,
Newport, RI
www.nesa.net
Sep. 12-14, 2008 Ohio Society of Anesthesiologists Annual
Meeting
The InterContinental Hotel,
Cleveland, OH
www.osainc.org
Oct. 17, 2008 American Society of Critical Care
Anesthesiologists Annual Meeting
Orlando, FL www.ascca.org
Oct. 17, 2008 Society for Pediatric Anesthesia Annual
Meeting
Orlando, FL www.pedsanesthesia.org
Oct. 17, 2008 Society of Neurosurgical Anesthesia &
Critical Care Annual Meeting
Orlando, FL www.snacc.org
Oct. 18-22, 2008 ASA Annual Meeting Orange County Convention Center,
Orlando, FL
www.asahq.org
Oct. 19-22, 2008 MGMA Annual Conference San Diego Convention Center,
San Diego, CA
www.mgma.com
Oct. 31–Nov. 2, 2008 Association of Anesthesiology Program
Directors/Society of Academic
Anesthesiology Chairs Annual Meeting
Hyatt Regency San Antonio,
San Antonio, TX
www.aapd-saac.org
Dec. 12-16, 2008 New York State Society of Anesthesiologists
Postgraduate Assembly in Anesthesiology
New York Marriott Marquis,
New York, NY
www.nyssa-pga.org
Jan. 23-25, 2009 ASA Conference on Practice Management Arizona Grand Resort,
Phoenix, AZ
www.asahq.org
ANESTHESIA
BUSINESS CONSULTANTS
255 W. Michigan Ave.
P.O. Box 1123
Jackson, MI 49204
Phone: (800) 242-1131
Fax: (517) 787-0529
Web site: www.anesthesiallc.com

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