Hello, my name is Mark Silverman, I'm here with my colleague Chris. We are here to talk to you today about a handful of things that entrepreneurial CRNAs need to know to protect themselves, to protect their practices, and to lead to fundamentally less need for lawyers than anyone should have to deal with. We want to thank Behind the Mask for the opportunity to participate in their podcast series. And before we really get going, Chris, do you want to introduce yourself? Sure. My name is Chris DeGrande. I am an attorney here at Venice Friedlander Copeland Narnoff with Mark. A lot of my practice is more focused on the transactional and corporate and regulatory structures that CRNAs deal with, as well as other healthcare practices. Mark is more on the litigation front. So yeah, I think we're going to talk about a lot of things for the, like Mark said, about the entrepreneurial considerations for a CRNA. I'll probably be kind of diving into some of the more corporate things, more corporate regulatory things to think about than Mark will be. Chris does the business stuff I do when the world sucks. Mark Silverman, I am a partner at Venish. I have been advocating for and guiding the CRNA community for over 12 years now. It's more than that. And I've had the pleasure of serving as the outside general counsel for over a decade for the American Association of Nurse Anesthetists. I still offer them, and nurse anesthesiologists, I still have the opportunity to offer guidance here and there and really appreciate the opportunity to add some insights and provide some information to the CRNA community that will hopefully be of value. So with that, Chris, we've discussed on some of these things in some of our other presentations, but why don't you give a quick overview of some things that you think the entrepreneurial CRNA needs to know from a business perspective? Yeah, sure. And so, you know, this is all kind of a, it's legal, definitely. It's also just kind of like business type of terms as well. But one of the things we had an entire podcast that we have done previously about this, so I won't go too deep into it. It was about 10 minutes ago, but it's about the corporate structure of the business entity you would want to be forming in order to start your CRNA business. And again, you'll hear a lot more about this in the other podcast, but generally speaking, it's understanding what kind of form you want to create that gives you the right kind of tax benefits and the right kind of protection from liability and the right kind of ease of running the entity that you feel comfortable with. What happens if you get it wrong? The business doesn't work and someone takes all your stuff. Yeah, I mean, that could happen. So it's worth spending the time, the energy, and the effort to get that right. Agreed. And then the next thing that I always say is important to consider is how you will be engaged to provide your services. Do you want to do this via, you know, like a professional services agreement where- Like an employment contract. Yeah, sort of like an employment contract where you as a CRNA are providing, you know, you enlist to provide your services to the, maybe like a surgery center. Or is the idea that, you know, say, or do you want to do it like on a per diem basis? Are you just doing it whenever they bring you in for a day? Do you want to be doing it on a scheduled basis? Do you want to be somebody's exclusive provider of anesthesiology services? Do you want to be non-exclusive where, you know, you got to make sure that you yourself are not being tied down if you don't want to be to only be providing those services to one person? So like the idea of being an employee versus a 1099, you know, as I recall correctly, we did a presentation on that too. We did do a presentation. You should watch that one also. And then another consideration would be how you would engage, if you're running a CRNA enterprise, how you might engage other CRNA providers that would be a part of your- If you're running an anesthesia staff and you can, how you're going to hire an anesthesiologist or a nurse anesthesiologist or however it might be. Yes. And so like two of the big considerations, and there are a ton to think about, but two that we've called out here, as Mark mentioned just a second ago, will these providers be employees of an entity you create? Will they be independent contractors? And another big one is if there are laws in the state where you're operating that would in any way prohibit the way you employ somebody. And so this concept, again, this is a concept is called corporate practice of medicine, which is basically that, and it's a very complicated concept, but the idea is that in certain states there are laws that prohibit a corporation from employing individuals who practice medicine, healthcare providers. The idea being they don't want a corporation who is business driven and money driven to be making healthcare decisions. And so there may be restrictions in certain states that would then apply to who you as a CRNA entity can employ. Like the example that would come to mind is as a CRNA company, if you wanted to have an independent contractor or employee relationship with say an anesthesiologist, there may actually be laws. Like a physician anesthesiologist. Like a physician anesthesiologist. So let me, but I mean, it's Google, right? Am I in a corporate practice of medicine state? That should be easy, right? Oh. Let me just ask this. How much more complex is your job when someone relied on Google to make their corporate decisions? Much, very, very complex. It always results, I mean, very often we get a lot of, I've looked it up, it says I can do this on Google and it gives me, it'll give us a big headache because the answer is probably much, much more nuanced. I actually have a really nice mug that says, please don't confuse your Google search with my law degree. So, all right. How about reimbursement? Because reimbursement doesn't drive healthcare at all, right? No, not at all. And so I think that it's very important to understand, you know, this goes with how your entity or your CRNA enterprise is going to be engaged. How are you going to be paid? Everybody wants to know how you're going to get your money. It'd be that. On what? Exactly. I want all of it. And the answer would be, or the questions would be, are you going to be billing for services you provide? Or are you going to be providing services to say, you know, some other surgical provider and you then get paid a stipend back, they bill for your services? So, understanding how that works, it's just, there's one business concerns that go into it. How much does that impact how much money you receive? And two, you're going to have billing laws that you need to be in compliance with, insurance law. There's all kinds of... There's even a little risk. We'll get to the company model a little later. Yes, exactly. Another thing to consider is your own protection from liability. And this is different from corporate liability. This is like, how do you protect yourself as a professional? Exactly. So, what I'm referring to here is more like insurance coverage. If you're starting your own enterprise, you're going to have to have your own liability insurance. And so, a thing that always comes up is, yeah, that is medical malpractice. That is also, there may be other types of insurance you have, directors and officers, general liability, auto insurance. And I will just say a little unsolicited pitch, but the AANA for years and years has been advocating to make sure that CRNAs have access to a marketplace filled with insurance options. They originally created the marketplace and then they've done a good enough job that others have entered in it. And so, AANA insurance services is a great resource and the AANA itself can help you get lots of information to make sure that you know what you need to do to protect yourself, to protect your practice. And then another big concern and a big issue that comes up a lot is understanding your relationships to know if contracting or working with any particular provider could have any impact on you working with other providers. That could be that maybe there is a non-competition covenant, but it could also just be, I mentioned earlier the exclusivity provisions. It may just, you know, always know if you're being engaged to provide services for something like a hospital or a surgery center that have they said that you are to exclusively to provide to them and know that, you know, if you don't read carefully and realize that, oh no, I actually can't go contract with other people based on the terms of this contract, that can be a severe damper on your expansion of your business. Okay. Now, fortunately, there aren't any regulatory issues or anything that CRNAs have to deal with. No, not at all. The ones that I deal with before I let Mark jump into the really heavy hitter ones, there's a lot, you know, that you have to worry about to make sure you're complying with like licensure and exclusion checks. So just the logistics of if you're starting your own enterprise and you have other CRNAs that are working with you, how are you going to track all the appropriate licensure to make sure all of your providers are appropriately licensed and licensed to make sure that you don't have somebody that has popped up on an, you know, an OIG exclusion checklist that, you know, got them excluded from Medicare or Medicaid. We're generally against that. Yes. Not, not an advisable business strategy. And then another big thing here is these next two bullet points are kind of related, which is understanding and monitoring your scope of practice and implementing the necessary oversight, supervision, prescriptive authority agreements. Again, so this is going to vary extremely heavily based on state and the requirements of the nursing and the medical boards. And the other thing that I'm going to say is this, you're also going to find that different employers have different requirements that they're going to impose, right? This is an area of sensitivity. Nurse anesthesia providers are trained to be independent licensed professional administers of anesthesia, right? That doesn't mean we don't have to deal with the politics of anesthesia. That doesn't mean you don't have to deal with the politics of your internal or individual employer. And the biggest trick is make sure you're spending the time and the energy to know what's expected of you, to know what's required of you, and to make sure that you're making the appropriate decisions to avoid or minimize unnecessary or undue risk for yourself. Exactly. Another thing that will become a, an issue when, you know, you start working with different providers is making sure that if you're at, say you're working at different surgery centers, working at different hospitals, understanding and ensuring the medical, you are appropriately on the medical staff. Could be close with the payers? Yes. And that's where the next one comes in too. Proper credentialing with payers, you know, is a lot dependent on making sure you're properly on the medical staff. Well, I can just list it under somebody else, right? Headache. We're going to recommend against that, but we'll say, I'll let you handle that in the next part about what could happen if you do that. And so, yeah, again, just understanding these medical staff requirements so that, you know, if you don't have it right, the way you get paid is by making sure everybody's credentialed correctly with payers. And look, the one thing you need to know when it comes to credentialing, it takes time. It does. And so it's one of those situations you need to build that in and factor that in because what it can do is it can legitimately create a real gap in your ability to receive appropriate reimbursement. And very candidly, if you do it wrong, it will even further slow down and it will start to detract from your ability to receive reimbursement. Excellent point, because that is true. You can sign up to do a relationship with a provider thinking you're going to start making money the next day, but if you don't take into account credentialing. The results are suboptimal. Yes. Long lag time. Okay. So I'm talking about the less positive side of billing. I'm talking about the fraud stuff. And let's just be candid. For some time now, the government's enforcement efforts with regards to health care are at all times high and the are all time highs. And the reason for that is pretty simple. That's where the money is, right? But let's also make it clear. It's also because people are doing it wrong and it's making it easy for them to target and go after and get money. So we have situations with upcoding. Upcoding is when you're falsely increasing the level of what care you're providing so as to receive more money. Kickbacks are when you are getting money in exchange for a referral. We're going to talk about that in greater detail specifically when we get to the company model. And then obviously there's the False Claims Act, the idea of submitting false, inaccurate claims to the government, which the government not only has the ability to recover, but to do so with some really unpleasant penalties. And as we'll talk about, there's some whistleblower provisions there. Upcoding is as simple as you can get. It's the thumb on the scale at the deli, right? When you ask for a pound of turkey and they put their thumb to make sure they get you to the pound, even though you didn't get the pound of turkey. The government is finding a lot of circumstances where they're using analytics-driven cases. Look, one of the things that causes a lot of these cases is the EOB gets sent to your patient and the patient who doesn't understand what was done or what was being done says, that's not the care I got. And so these are things where having good, accurate records is going to be the greatest defense that you can ever have. And the only way you're going to get that is if you set your systems up correctly and accurately in the first place. If you don't, oh, by the way, for this, don't lie, I mean, at the end of the day, that sounds like that's not that hard to do, but don't lie. It really reduces your risk, amazingly, if you tell the truth. But anyone can get audited. Anybody can have to deal with this. And if you don't have it set up well, and if you can't explain what you've done, why you've done, and don't have the documentation to back it up, candidly, you end up needing someone like me. And I'm very pleasant, but, you know, I'm a great guy to know, I'm a lousy guy to need. So keep that in mind. Most common examples of upcoding, you're going to lie about how much time, you're going to lie how serious or severe the patient's condition was, you're going to pretend you did four of the procedure when you only did two, or how often it happened, or again, just blatantly making crap up. And I say that, but I have, I will tell you, I have seen circumstances, you will never be able to shock me with what's out there, what's alleged. And what you need to understand is that best case, this is going to yield the government wanting a good amount of your money. But the good news is, if you do it well enough, you don't have to worry about money because they're going to offer you free room and board for an extended period of time. These are situations worthy of avoiding. All right, the kickback statute, the anti-kickback statute basically makes it criminal to exchange anything of value in exchange for the referral of a service that is being paid for by a federal government health care program. So who are we talking about? Medicare, Medicaid, TRICARE, it is getting a lot more complicated as you now get into some of the private federally, you know, when you get into managed care organizations, there's a lot more nexus with the federal government than you ever realized, and that you may not have intended. And at the end of the day, I didn't realize this was the government, I thought I was ripping off, you know, a private commercial insurer, not a very good defense. The other thing that you have to remember is this. I remember early in my career, I was standing in a courtroom and I watched two attorneys handling a business dispute, their clients were there and their clients were very unhappy. And one of the clients, this was in the context of health care, said, I don't know what he's complaining about. I've been paying him kickbacks for 20 years. And the reaction was just, because what you need to understand is liability for a kickback goes in both directions. Just because one person is shaking down the other doesn't mean that the person being shaken down and paying the kickback isn't also breaking the law. The other thing is the government's getting aggressive about this. It doesn't have to be the only reason you paid the money. If one of the reasons, one of the purposes for the money exchanging hands was to encourage the referral. Right. And by the way, let's be clear, this is not solely unique, but somewhat unique to health care. Right. As a lawyer, shockingly, we've set the law that I can pay another lawyer for sending me a case. Very nice to be the ones who write the laws. Right. But no one's really concerned if lawyers treat each other crappy. We are concerned about financially incentivizing health care and health care decisions. Again, the principle is great, but so you just need to know. And again, every incident, every incident of a kickback could yield up to five years in prison or a fine of up to twenty five thousand dollars. The penalties are real. And for those of you who are like, well, why didn't you just you can also yield exclusion from Medicare, Medicaid, TRICARE, which if you can imagine trying to practice health care with no access to the ability to provide in Medicare and Medicaid. And let's also be honest. Most commercial payers have provisions that if you've been excluded from Medicare or Medicaid, they will not. That's what I was going to say is it may not just exclude you from Medicare and Medicaid. It can exclude you from a commercial payer that requires that you are certified by Medicare. So here's why this plays into the company model. Let's be candid. Most anesthesia providers are not randomly walking around just anesthetizing people. Right. It is generally frowned upon to be sitting on the bus and just, you know, put someone out. So usually when you're administering anesthesia, it is related to some other healthcare service that's being provided. And therefore, if you are not an employee, someone is bringing you in for the purposes of performing that procedure, performing anesthesia to support that procedure. That is like, let's use the easiest example is a surgery center, right? So the company model has come about where what happens, and this isn't over generality, but I'm gonna describe the most common circumstance where what you have is you have a group of physicians who own a surgery center and they are, you know, contracting out with the provider of anesthesia for the administration of anesthesia. And what they eventually realize is this is a lot of money that we're giving away to somebody else. So here's what we're gonna do. We are gonna create our own anesthesia billing company and we're gonna bring you in and we're gonna ask you to assign your billing rights to us. Now, is there anything about that that's illegal? No. Okay, we're good. And then they are going to bill the services and they're gonna pay you. And there are ways to set this up where they can pay you. That is fine. However, what often happens is let's just say that the average in a community for the value of billing services is 8%, right? If they are billing your services and they are keeping 8% and the purpose of that 8% is because that's the value and the cost of the anesthesia billing services we're providing, again, you're great. The problem is they don't always want 8%. Sometimes they want 10, 15, 20, 25%. And the question is why? And what you have to understand is oftentimes, sometimes spoken, sometimes not, the answer is I'm sending you the case. I want the money. Gosh, that does sound like they're looking for money in exchange for the referral of the healthcare service that is being billed to the government. And what you also need to know is private insurance companies usually have clauses in their programs that prohibit these types of payments. It doesn't necessarily have the same criminal consequences but it can still violate various provisions. And at the end of the day, look, sometimes you might have it where they're providing other services, where they're doing all of these different things and it might be a higher rate. The question is, can you justify and can you explain why there's money changing hands? Because anytime you have a situation where one party is referring business to another and there's money flowing back, that money is gonna be subject to increased scrutiny. And what I will tell you is a lot of times people are creating all of these, well, we're gonna provide this service and that and training and all of these things and that's how we're gonna justify the 18% we want but then they're not doing it. And it's amazing that the government will look at that and say, wow, that looks like you not only were making a kickback, you were aware it was a kickback, you tried to hide it, you lied about it and now you're even more in an unpleasant situation. So this is hard. Why is it hard? This is hard because a lot of anesthesia providers are like, okay, but if I say no, this is illegal, there's somebody behind me who's willing to take this deal. And I get it, I get it. All I can do is tell you what the law provides and what the risk is. And ultimately you make a determination of your own degree of risk tolerance. The worst thing is there's a lot of circumstances where this is being done and it isn't getting the attention and it isn't getting called out. And there've been advisory opinions. I think this advisory opinion model that we have here seems to encourage a way to allow what they couldn't do directly. It allows them to get some degree of compensation for the provision of anesthesia services. Let's be candid. Ultimately, all this is doing is shaking down an anesthesia provider for some of the money that they are entitled to and that they're earning. So this is literally never to the benefit of the anesthesia provider. The problem is this, if it's happening and the government decides it cares, the liability goes in both directions. And when people say to me, but everyone is doing it. The example I give is this. When you drive down the road and you wave at the police officer who's standing next to the 35 mile an hour sign, driving 45 miles an hour past him every single day and he waves and you wave. The day he pulls you over, the fact that he allowed it a whole bunch of times change that it's illegal. And the fact that there are 10 cars driving by at 45 miles an hour and the officer pulls you over doesn't act as a defense. So ultimately all we can do is tell you what the laws are and what the risk is and help you evaluate that. I will tell you there are some articles. I could be wrong, but I think one that I did that described this in the ANA journal. You might wanna look to that as a resource. So my warning is before you accept anything of value and anything of value isn't just money. It can be the trip to the Superbowl. It can be any number of things. It's literally defined as anything of value. Before you do that, where it relates to the fact that you're providing services for the government, stop, slow down, evaluate your risk, coordinate with a lawyer. Because what I will tell you is I have encountered many clients who have faced these allegations and none of them have concluded that the value or the consequence or the cost was worth it. So any thoughts here? I mean, you work routinely with clients to help them avoid this. I do. And I mean, it's a big, where I come in is I try to be ahead of the issue. Avoid the problem. Yes, avoiding the problem of structuring a relationship between an anesthesia provider and then like a surgery center or a hospital in a way that we don't have this problem. And so that has, you know, that has had me on the phone and discussing with other providers like, hey, here's the reason there's a risk to this. And you guys know that we should structure this and make sure we're avoiding that risk. And I mean, how often do your clients say, look, this isn't gonna work to my disadvantage if I try to draw this line. But then what he does is he introduces them to me and tells them that I get paid by the word. So that usually makes them willing to avoid that self-deprecation, that's fine. Okay. I'm gonna move on to the False Claims Act. The False Claims Act is a longstanding law. It's existed literally since civil war times, but it has been revitalized and revised in the last, you know, 15, 20 years. It is basically a opportunity for the government to recover money for services to the government where the government didn't get its value based on the provision of false information, inaccurate information, anything that misled the government to provide the services. And the way that you violate the False Claims Act is either intentional fraud, like you submit a claim that you know to be untrue. So if you submit a claim for services that weren't provided, if the government wants to, they can just charge you with fraud and send you to prison. But they can also charge you for, and I guess it is alternative or also, they can also charge you to get back the money. And then there are fines and penalties. The government's allowed to recover up to three times as much as they paid you. Plus there is a per claim recovery that has been increasing and increasing and is now over like $25,000 a claim. Per claim. Per claim. So what I want you to think about is imagine how many times you do something in healthcare. If it is wrong and you do it, because I always joke, my common comment to the government is, this wasn't 6,000 mistakes. It was one mistake that was repeated 6,000 times. And they don't seem to understand the importance of that. But if they say there are 6,000 claims, I mean, I'll let you do the multiplication. I'm on this, but what's 6,000 times 25,000? I'm guessing it's a lot. It's a lot. I was about to say, I've been now practicing. I've been practicing law as long as you. It's been about eight years. And still the numbers, when I try to do the math in my head of each time I hear the per claim, how many times that claim must've been entered continues to like- It scares you. So now this is where we get into some stuff and we'll talk about this. We'll touch on the idea of TEFRA or even if you've assigned your billing privileges. It's not just knowingly submitting a false claim. It's also if you cause someone else to submit a false claim or if you make a false record, right? That yields the payment of a false claim or obviously if you conspire with somebody else to do so. That's how you can yield yourself FCA liability. But the other thing that you have to remember is that there's a whistleblower provision, right? The whistleblower provision is effectively the government has deputized everyone. If you know about fraud, let us know and you can get a percentage of it, right? But they've created a new generation of, okay, there are times where it roots out really good fraud. It is altruistic, it is good and it has really protected the government and the public and I'm not minimizing that at all. But there's also a new kind of ambulance chaser evidence which is that people are just throwing out, seeing what they can do to get settlements, seeing what they can do to get their huge payday and it allows you to continue these lawsuits even after the government has decided they're not gonna participate. They don't see the validity or they don't see the interest or it's not big enough for them and the problem is defending these lawsuits can cost hundreds of thousands of dollars and they use that as an opportunity to negotiate settlements even where the legal principles might not justify them. I'm not saying that's everyone who does false claims act cases. I'm not trying to be completely disrespectful, just disrespectful to a small portion. And if you're not offended, that means it definitely wasn't you that I was talking about. The biggest issue that I will tell you is that bringing a false claims act case when the medical necessity or the quality of the care was questionable is what really is frustrating the heck out of the government and candidly, the cases they bring were, I mean, the most awful example of this is the circumstance where there was the doctor in Michigan who was faking people's cancer diagnoses and administering in, what do you call it? Chemotherapy to them just to make money even though now that was ultimately charged criminally but it was also subject to and it may also have been given false claims act treatment because he was submitting all of these claims to the government that were not real. Look, the only thing I can say with regards to this is if you do horrible things, you should expect horrible things will come. Just don't, please don't. And by the way, it gives you reason to make sure that if you're doing something where the medical necessity or the quality of what you're doing isn't evident, document it, document it in advance so that if someone does raise a question or raise a concern, you can explain what you did and why. The other thing I will tell people is just, yeah, pretending you don't have a problem, it's what I call the ostrich defense. Sticking your head in the sand, pretending you don't have a problem just doesn't solve it. And when, I mean, what I always say is this, if you find you have a problem, there is a self-disclosure process, there are overpayment options, there are ways to minimize your risk, right? But hoping it will just go away or hoping no one will notice is a risk and it is a challenge and what I will tell you is you have to remember since almost all of the evidence is gonna be available within the medical records that you maintain and the billing materials you've submitted, they already have the billing materials, they have access to your records at any given time through departments of public health and other investigative agencies. So I'm just saying, again, don't suck, rule number one, good records, so if someone asks a legitimate question, you can explain it and when you find the problem, just don't pretend it's not there. One of the things that I hear all the time is, well, I signed my billing rights, so I don't have to worry about this, right? So this is again, a massive matter of frustration for me because it's easy for me to say, look, you have an absolute right, go to your employer and tell them you'd like a copy of what was billed under your credential and they're going to look at you and say, screw you. I mean, they're gonna say that because what they think you're trying to do is find out how much money they made off of you so that you can negotiate for a higher degree of reimbursement, right? Even if what you're trying to do is just make sure that there was nothing improper billed under your credential because ultimately, you can still be held responsible for what was billed under your credential. The simple argument of, I didn't know, I trusted them, may help you with criminal liability, it could still yield your exclusion, it could still yield significant problems and so I'm not telling you, don't assign your billing rights, I know a lot of employers do, but if you can negotiate that you have access to that information so that you can perform a periodic audit of it or test of it, it's a great way to protect yourself. But this idea that you don't have responsibility or you don't have risk because you assigned your billing rights to someone else is just not true. Like I said, the negotiating in the contract part of that, the negotiating when you're doing like an anesthesia services agreement, ability to audit is, I always stress. Good, yep. So we're gonna go through this quickly. There are three types of liability, civil, administrative, criminal. In its most basic form, civil is they want your money. Administrative is they're coming after your license. Criminal is they're coming after your freedom. Civil liability, overpayment, recoupments, damages and people are gonna come after whoever they can to get the money. Administrative liability, that can be a lax against your license, it can be act against your certification, it can be an exclusion, it can be an audit. There's all sorts of different things. And ultimately it can materially affect your ability to pursue your professional career. And criminal liability, let's just be candid. You need two things. In law school, we call it actus reus mens rea, criminal act, criminal intent. See lawyer. That's a throwback. That's lawyer Latin. You both need a criminal act and you need a criminal intent, right? And that means you need to have done something wrong and you need to have intended it. And at the end of the day, if you put the two of those together, you are at risk for fines, fees, freedom, all of which are worth avoiding. So, and willful unreasonable ignorance. Well, I just, I made a point of not asking or paying attention or knowing. It just doesn't matter. That's not enough. And this I mentioned earlier, the idea that just because someone else is submitting bills under your name, under your NPI, that doesn't protect you or preclude you from having liability. So the best thing that you can do besides doing everything right. And I don't mean that cavalierly. I'm just saying the better practitioner, the better you communicate, the better you talk to people. The one thing you can also really control is the better you document. Maintaining good records. It's what gets you paid. It minimizes the degrees of audit. It minimizes degrees of denials. It minimizes the opportunities for overpayment or self-disclosure. And from a lawyer's perspective, you can look at it either way. Everything you put in writing can be used against you, but what isn't there keeps me from protecting you. And so what I would say is if you have good processes, good models, and you submit, you stick to them, it's gonna take a good lawyer. It's gonna give them the ability to protect you and to defend you if the situation requires it. So look, at least I'm consistent. Be deliberate, be detailed, be distinctive, be honest, be consistent. Don't get me wrong. If someone's coming after you, they'll figure out how to use all this against you. But if you have a good advocate, it will be much easier for us to protect you with information than to protect you without. This is my personal thing. Never put profits ahead of patients. You can tell when people are doing it. If your focus is providing quality care, one of the reasons I love the CRNA profession is, like one of the guidance I give when I'm talking to young CRNAs is always, never give up that aspect of you that is and was a nurse. And I say is and was because you don't give up being a nurse when you begin administering anesthesia. But if you go all the way back to watchful care, what was it that made nurses more and better attuned to administering anesthesia than physicians at that time was that the young surgeons that they were relying on to administer anesthesia were more interested in the surgical procedure going on than they were in the patient. And it was the nature of the nurse to be able to tune out everything, focus on the respirations of the patient, focus on them tuning out everything else. And that fundamental nature of being a nurse was what made them so well-suited for the administration of anesthesia. And that fundamental nature of nursing continues to be an asset that I just, I wanna encourage people not to let go. And communication will always benefit you as long as you don't say anything stupid. Okay, this is been a broad touch on a variety of things. If you have questions, if you have things we didn't address, if you have other concerns, please don't hesitate to reach out. If there's a subject that we touched on that you'd love to learn more about, we can point you in the right direction. We're not just trying to sit here and get business. If you have something going on in your jurisdiction, we may well not be the right people to help you, but we're more than happy to try to help you find someone who can. Avoid the problem is always better than fixing it. So with that, I wanna thank you for your time. Chris, I wanna thank you for joining me for all of these today. I want to give my standard disclaimers, I have to. I want to thank Behind the Mask for giving us the opportunity to participate and everyone should have a great day. Thank you very much.

entrepreneurial CRNAs

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corporate structures

billing arrangements

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