Post on 15-May-2018
Page 3 April 28, 2015
Prepared for GMGMA
“If you don’t know where
you’re going, you might end up
somewhere else.” Yogi Berra
Page 5 April 28, 2015
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Managed Care Trends To Watch
• Fewer payers (mergers)
• Medicare is the allowable standard
• Pay for performance
• Price transparency
• Providers dropping Medicare/Medicaid
• Concierge
• Affordable Care Act
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Impact On Your Practice
• Confusion reigns
• Higher copays/deductibles (better or worse
cash flow?)
• Decrease in pre-certs, streamline referrals
• Decrease in utilization?
• Patients shopping prices and compatibility
Page 7 April 28, 2015
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Why Is It Important To
Manage Your A/R?
• Cash Flow
• Monitoring managed care contracts
• Patient perception of practice
Page 8 April 28, 2015
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Why Is It Important To
Manage Your A/R?
If you plan, you act on your environment. If
you don’t, your environment acts on you!
Page 9 April 28, 2015
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A/R Myths
• “Bill it and it will come.”
• “We have a contract so they will pay our
contracted amount.”
• “Co-payments are small potatoes.”
• “Sally is great at the front desk. Let’s
promote her to A/R clerk.”
• “Refile. Refile. Refile.”
Page 10 April 28, 2015
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Set Expectations
• New patient first call
• Patient information
• Signs
• Brochure
• Financial policy
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Maximize Time of
Service Collections
• Collect copayments before the visit
• Accept all forms of payment
• Convert checks to debit
• Initiate payment plans – get deposit
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Maximize Time of
Service Collections
• Your copayment today is $_________.”
• Silence - option to refuse or ask for
concession is on patient.
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Page 13
Maximize Time of
Service Collections
$ 20.00 Copayment
Total Visits/Month
Insured
Visits/ Monthly Quarterly Annual
% Insured
(30 pts/day x 22
days) Month Copay $ Copay $ Copay $
5% 660 33 $660 $1,980 $7,920
10% 660 66 $1,320 $3,960 $15,840
15% 660 99 $1,980 $5,940 $23,760
20% 660 132 $2,640 $7,920 $31,680
25% 660 165 $3,300 $9,900 $39,600
30% 660 198 $3,960 $11,880 $47,520
35% 660 231 $4,620 $13,860 $55,440
40% 660 264 $5,280 $15,840 $63,360
45% 660 297 $5,940 $17,820 $71,280
50% 660 330 $6,600 $19,800 $79,200
Page 14 April 28, 2015
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“Right From The Start”
Front Desk Role
• Accurate data entry - patient demographics,
insurance information
• Insurance verification - prior to each
appointment
• Referrals - if requested
• Pre-certifications - as required
• Contractual requirements for ancillary services
Page 15 April 28, 2015
Prepared for GMGMA
Clinical Staff Role
• Ensure all procedures and diagnoses are
captured on encounter form
• Checks patient insurance type prior to lab,
diagnostic requisitions, or hospital admission
• Obtains pre-certifications
• Obtains non-covered services waivers
– Advanced Beneficiary Notice
Page 16 April 28, 2015
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Physician’s Role
• Document, Document, Document!! – ICD-10
• Note all procedures on charge capture form (including hospital work!)
• Note any special circumstances
• Refer all billing/financial questions to billing staff
Page 17 April 28, 2015
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Top 5 Reasons Physicians Should
Learn About Coding
• Increase reimbursement
• Decrease time spent on documentation
• Experience fewer claims denials
• Improve understanding of bottom line
• Avoid fines, penalties, jail time
Page 18 April 28, 2015
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Beware…. ICD-10-PCS is on its way
• 7 digits, not 5
• Each can be either alpha (not case sensitive) or numeric
• Numbers 0 – 9 are used
• Letters O and I are not used to avoid confusion with numbers 0 and 1
Examples
• 0680ZZ Division, inferior vena cava, open
• 0DQ107Z Repair, esophagus, upper, open with autograft
Page 19 April 28, 2015
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A/R Management Procedures
• In writing
• Timely
• Adhered to
Page 20 April 28, 2015
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Manage A/R Process
• Establish (& follow!) aggressive patient
collection protocols
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Patient Collections
Statement cycle
• Point-Of-Service/
On demand
• 30 days
• 60 days
Telephone Intervention
• 5-8 p.m.
• Documented
• 30-45 days
• Collection agency
• Release from practice
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Manage A/R Process
• File claims electronically & daily
• Review transmittal report for claims problems
• Re-file corrected claims
Page 23 April 28, 2015
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Manage A/R Process
• Re-file selectively
• Don’t forget secondaries!
• Touch claims between 30-60 days
– 45 day report
Page 24 April 28, 2015
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Manage A/R Process
• Utilize demand & cycle billing
• Utilize electronic statements
• Track denials/rejected claims
• Work denials
Page 25 April 28, 2015
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18% of All Claims Are Denied Due To
[Practice Controlled] Billing Errors
• Incorrect or missing
subscriber number or
group number
• Provider’s signature
(or facsimile) missing
• Diagnosis is missing,
incomplete, or non-
existent
• Procedure codes are incorrect or missing
• There is no correlation between procedure codes and diagnoses
• Modifiers were used for procedural codes but were not explained in narrative
Page 26 April 28, 2015
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2. Manage A/R Process Odds of collecting after date of service
97%94%
84%
74%
58%
43%
27%
0%
20%
40%
60%
80%
100%
< 30
days
30 60 90 180 270 365
Page 27 April 28, 2015
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Page 27
What Are Your Timely Filing Limits?
Medicare 15 months (10% penalty
after 12 months)
Medicaid
BCBS
United Healthcare
Page 29 April 28, 2015
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Manage Your Contracts
• Find & read contracts
• Negotiate untenable points
• Negotiate fixed fees/fixed RBRVS
Page 30 April 28, 2015
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Manage Your Contracts
• Share contract terms with staff
• Utilize computer system technologies
• Watch carve outs, bundling, etc.
• No fees allowed at 100%
Page 31 April 28, 2015
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Multiple Fee Schedules
HMO PPO POS What was paid
99213 $47.35 $70 -- $43.85,$32,$37.50, $37
Page 32 April 28, 2015
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Solution
• Load each contract fee schedule
• Poster reviews each payment for accuracy
• Re-file for corrected payment (passive)
• Contact provider rep (aggressive)
Page 33 April 28, 2015
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Delayed Payments - Solution
• Contact provider rep
• Letter to Plan President
• Open complaint with State Insurance
Commissioner
http://www.inscomm.state.ga.us
Page 34 April 28, 2015
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Is Payer Paying/Allowing 100% of
Your Submitted Charge?
• Fee below UCR
• Leaving money on the table
Page 35 April 28, 2015
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Tools To Evaluate A/R
• Billing Policies & Procedures
• Financial Benchmarks
• Management Reports
Page 36 April 28, 2015
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Billing System Reports
• Aged A/R by Payer (Summary & Detail)
• Detail Self-pay Aged A/R
• Claims Pending
• Monthly Charges/Payments/Adjustments
Page 38 April 28, 2015
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A/R Indicators
• Gross collection rate
• Adjusted collection rate
• A/R ratio (months charges in A/R)
• Percentage A/R aging
Page 39 April 28, 2015
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Benchmark 1: Gross Collection Rate
What percentage is the practice collecting of
what it charges?
FFS Collections
FFS Charges = %
Page 40 April 28, 2015
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Gross Collection Rates
55.3%
33.7%
36.5%
42.8%
66.4%
42.9%
49.8%
Family Medicine
General Surgery
Orthopedic Surgery
Cardiology
Pediatrics
OB/GYN
Internal Medicine
Source: MGMA Cost and Revenue Survey: 2014 Report Based on 2013 Data, Sincle Specialty Practices, All Ownership, Median Values
Page 41 April 28, 2015
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Benchmark 2: Adjusted Collection Rate
What percentage is the practice collecting of what it is allowed to collect?
FFS Collections
FFS Adjusted Charges* = %
*charges minus mandated adjustments
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Page 42
Example:
• Office visit = $100
• BC/BS Write off = $15
• Collected $80
Gross Collection Rate =
$80
$100 or 80%
Adjusted Collection Rate =
$80
($100 - $15) or 94%
Page 43 April 28, 2015
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Adjusted Collection Rates
97.0%
92.2%
94.9%
94.8%
98.0%
96.5%
97.5%
Family Medicine
General Surgery
Orthopedic Surgery
Cardiology
Pediatrics
OB/GYN
Internal Medicine
Source: MGMA Cost and Revenue Survey: 2014 Report Based on 2013 Data, Sincle Specialty Practices, All Ownership, Median Values
Page 44 April 28, 2015
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Benchmark 3: A/R Ratio
How many months worth of charges (work) are in your
Accounts Receivable?
A/R Balance
Average Monthly Charges = Ratio
Page 45 April 28, 2015
Prepared for GMGMA
A/R Ratio
0.94
1.16
1.35
1.05
0.82
1.15
0.93
Family Medicine
General Surgery
Orthopedic Surgery
Cardiology
Pediatrics
OB/GYN
Internal Medicine
Source: MGMA Cost and Revenue Survey: 2014 Report Based on 2013 Data, Sincle Specialty Practices, All Ownership, Median Values
Page 46 April 28, 2015
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Benchmark 4: Calculating Overhead
Total Expenses
<Physician’s Salaries>
<Physician retirement>
Net Expenses ÷ Total Revenue
Page 47 April 28, 2015
Prepared for GMGMA
Total Operating Cost
72.4%
87.2%
51.4%
59.6%
60.4%
80.8%
68.7%
Family Medicine
General Surgery
Orthopedic Surgery
Cardiology
Pediatrics
OB/GYN
Internal Medicine
Source: MGMA Cost and Revenue Survey: 2014 Report Based on 2013 Data, Sincle Specialty Practices, All Ownership, Median Values
Page 48 April 28, 2015
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Calculating Employee Expense
Total Employee Salaries
Net Revenue
Page 50 April 28, 2015
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What Are Internal Controls?
Methods and procedures used to…
• Prevent, detect errors
• Encourage adherence to policies
• Safeguard against misappropriation
Page 51 April 28, 2015
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Fraud Risks
• Desperate people do desperate things
• Regulatory requirements
• Competition
• Rapid changes
• Need for capital
• Complex transactions or structure
• Absentee owners
Page 52 April 28, 2015
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How Fraud Occurs
• Poor internal controls – 60%
• Management override – 35%
• High risk industry – 33%
• 3rd party collusion – 33%
• No ethics policy – 8%
• No director control – 5%
• Other – 2%
KPMG Study
Page 53 April 28, 2015
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Red Flags
• Personal financial pressure
• Vices
• Extravagant lifestyle
• Real or imagined grievances
against the company or
management
• Increased personal stress
• Management pressure
• Short vacations,
unexplained hours
• Overly neat, territorial
• General lack of ethics
• Unusually close
vendor relationships
Page 55 April 28, 2015
Prepared for GMGMA
Question 1
Do you know the typical daily, weekly, and
monthly volume of your practice, and do you
promptly investigate any material deviations?
Page 56 April 28, 2015
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Question 2
Are charge slips, cash receipt slips,
and checks pre-numbered, controlled
and accounted for, including voids?
Are blank documents stored safely and
is access limited?
Sally “loses” her friend’s charge ticket.
No charge = No write off = No money
Page 57 April 28, 2015
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Question 3
Are cash-related duties appropriately segregated among your staff members?
Recordkeeping vs. custody vs. approval
– Who opens the mail?
– Who posts payments?
– Who does the bank reconciliation?
– Who reviews the payroll journal?
Page 58 April 28, 2015
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Question 4
Are your accounting records, including
charge posting, payroll reports, and bank
reconciliations, kept up-to-date and balanced
daily and monthly?
– Monthly daysheet reconciliation
Page 59 April 28, 2015
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Question 5
Do you restrict check signature authority to
physician owners only, insist on personal
signature instead of a signature stamp,
and inspect back-up invoices before
signing checks?
– All parts of the check are complete; original
invoice approved and canceled; packing slip
attached; expenditure is reasonable.
Page 60 April 28, 2015
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Question 6
Are all checks stamped with the practice’s
“For Deposit Only” endorsement stamp
immediately upon receipt? Are un-deposited
checks stored in a safe place pending
deposit?
Page 61 April 28, 2015
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Question 7
Are all employees required to take annual
vacations? Is there a backup person for all
positions?
– Big bus theory
– “her way” versus the right way
Page 62 April 28, 2015
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Question 8
Are all contractual adjustments, patient
refunds and non-contractual write-offs
approved or monitored by an authorized
supervisor?
– Ignorance? Innocent mistake? Deliberate?
Sally’s friend incurs $3,500 in patient responsible
services. Sally’s choices:
- Put friend through normal collection procedures
- Write friend’s balance down to zero
Page 63 April 28, 2015
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Question 9
Do you check the references of new hires
carefully and screen candidates and
current employees regularly for exclusion
from or sanctions by Medicare and other
federal programs?
Do you obtain a background check/credit
report?
http://exclusions.oig.hhs.gov
http://epls.arnet.gov
Page 64 April 28, 2015
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Question 10
Do you use the “sentinel” effect?
Occasionally sample postings, review the
general ledger, inspect reconciliations, check
the cash drawer and ask questions?
Page 65 April 28, 2015
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Staffing Success:
Hiring, Retaining, &
Growing Good Employees
Page 66 April 28, 2015
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Staffing Reality
• Good employees are hard to find
• Once found, they’re hard to keep!
– Average employee changes jobs every 2-3 years
Page 67 April 28, 2015
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Staffing Reality
• Everyone is looking for the same thing –
– Good work ethic
– Job knowledge/skills
– Customer service
• SHORTAGE of these people!
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Staffing Reality
And good staff is hard to keep
– 1 in 4 workers has been with their present
company for less than one year
– Gen Y – average of 14 jobs before they turn 38
– Turnover is a reality
– As many as 44% skilled worker and 23% of
executive resumes contain at least some lies
Page 69 April 28, 2015
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Pre-Hiring Process
• Job description
• Advertisement – language, venue
• Review/Rank resumes
Page 70 April 28, 2015
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Hiring – Successful Interviews
• Telephone interviews
– LISTEN!!
– Share
– Inquire
– Inform
Brief interactions but POWERFUL!
Page 71 April 28, 2015
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Hiring – Successful Interviews
• First face to face interviews
– Observe – promptness, appearance, ability to
engage in conversation?
– Ask questions and listen to the answers!
oTell me about a time you….
Past performance is best predictor of future!
Page 72 April 28, 2015
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Hiring – Successful Interviews
• Second interviews
– Practice tour
– Half day/day visit
– Utilize staff (but not a consensus decision)
– Overview of structure, may include general
explanation of benefits but not $$
Page 73 April 28, 2015
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Due Diligence
• Reference checks
• Background checks
• OIG/EPLS websites
• Style assessments – DISC
– Insight as to how employee may respond in your
practice
– Provides additional interview questions/points of
follow-up
Page 74 April 28, 2015
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Practice Integration
• Term sheet (not contract)
• Employee Handbook
• Employee training & orientation
Good integration can lead to better retention!
Page 75 April 28, 2015
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New Employee DON’TS
DON’TS
• Don’t have new employee start on Monday!
• Don’t throw new employee to the wolves!
• Don’t rely on the “Sally trained Sara who
trained Sandy who trained Susan”
methodology!
Page 76 April 28, 2015
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New Employee DOs
DOs
• Do have new employee start on a slower
week day.
• Do have a planned orientation and integration
schedule.
– Include a checklist and have employee sign that
orientation occurred for each topic.
• Do review job description (again!).
Page 77 April 28, 2015
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New Employee DOs
DOs
• Do provide resources.
• Do give employee a tour and introduce them
to everyone again.
• Do explain benefits, pay structure, etc.
• Do share practice philosophy and tips for
success.
Page 78 April 28, 2015
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New Employee Training
• Do allow hands on practice.
• Do differentiate between listening (passive)
and hearing (active).
• Do use “tell me” and “show me” as you train
to ensure grasp of concept.
Page 79 April 28, 2015
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Page 79
Competitive Pay
/Benefits
Good Environment
Good Management
Retention
Page 80 April 28, 2015
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Employee Debate: Should I Stay?
• Learning/growth opportunity
• Competitive salary/benefits
• Favorable environment
Page 81 April 28, 2015
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Employee Debate: Should I Go?
• Stagnant wages/benefits
• Poor management
• Negative culture/work environment
Page 82 April 28, 2015
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Why Employees Leave
1. Their boss
2. Not recognized or appreciated
3. No say in work or decisions
Page 83 April 28, 2015
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Employees Really Want to Work
• For a company they can identify with
• Where they are enabled – have supervision,
authority, information and resources needed
to be successful
• Where they are rewarded for their successes
• Where they can develop productive
workplace relationships with coworkers
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Signs of Disengagement
• Sudden “9 to 5” time clock mentality
• Unwillingness to participate in social events
outside office
• Tendency to isolate self from peers
(especially if contrary to their personality)
• Sense that something is not right but you
can’t put your finger on it
Page 85 April 28, 2015
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Good Management
• Address problems
• Make decisions
• Provide feedback
• Instill fun
• Catch them being good
• Rewards don’t have to monetary
• MBWA
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Your Role as Administrator
• Communicate
• Set expectations
• Coach
• Educate
• Foster Growth
• Lead by example
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Your Role as Administrator
• Leader
• Coach
• Financial Officer
• Human Resources
Manager
• Banker
• Marketer
• Police Officer
• Cheerleader
• Bill payer
• Babysitter
• Facilities designer
• Landlord
• Decorator
• IT Manager
• And the list goes on…
Page 88 April 28, 2015
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Thank You!
Lori A. Foley, CMA, CMM, PHR Principal
lfoley@pyapc.com
Pershing Yoakley & Associates, P.C. www.pyapc.com 404-266-9876