I want to provide you with three simple tools, as I said, something that's easy to do. You can take home and answer a few key questions about profitability, about joining insurance networks. So these tools should help you determine your particular value proposition within your own practice, understand the stakeholders in your local market, determine the financial feasibility of payer relationships, and select the right type of model for your practice. So let's start out with the first one. This is a really simple tool. It's a SWOT analysis. So you're identifying strengths and weaknesses within your own practice, and then you're also identifying opportunities and threats, and these are outside of your practice. And this can be really simple. You go through, you're just putting a pen to paper. The reason I chose this is it's cheap, it's cost effective, you can sit down for five minutes with your team, and you can come up with some of these. These strengths, weaknesses, opportunities, and threats, these are those quality measures that I was talking about originally in that paradigm. You know, look at when we first started, the things that we had going for us, my dad was a very passionate provider. We had a great screening program coming from his general practice. He was an excellent communicator with patients. He could close patients. He could get them to understand the risks of untreated obstructive sleep apnea, and he could get them to accept the importance of therapy. We had a really low labor cost. We never paid him for years. We had a really dedicated team to dental sleep medicine. As I mentioned, we were solely focused on dental sleep medicine. It was our single focus. And we had the patient preference going our way. You know, when we looked at weaknesses, we didn't understand medical billing at all when we started. We had no understanding of the medical necessity criteria needed to get treatment covered. Dentists as a whole, and my father was no exception, knew nothing about evaluation and management documentation and coding. The EMR became crucial with respect to helping us understand these things. We had no administrative policies and procedures, no clinical business systems, no major sleep education. We had to go back to school. We had very few treatment options. As I mentioned, it was one appliance. One appliance when we started. There was limited research and awareness of oral appliance therapy when we got into the market. When I first went out to talk to sleep physicians, they would kick me out of their office. You're going to break patients' teeth, is what they would say. You know, the patient cost was a major factor when we started. There was no insurance coverage. You know, so everyone was paying out of pocket with limited research, knowing side effects and so forth. It was hard to get acceptance over the therapy. So you need to take some time for yourself and write down the weaknesses. Write down your strengths. What do you see as your value proposition within your own practice? What are the opportunities that you have in your local market? Maybe there are insurance network insufficiencies, and some of the insurance folks were up here talking about the ability to get gap exceptions approved. Maybe you can stay out of network. And maybe you can charge your charge and balance bill patients and get what you want financially from the service and still provide some insurance payment for the patient. There's strong demand for PAP alternatives. That's a great opportunity. Medical insurance coverage, even the option of credentialing. This didn't exist when we started. When we went to payers, they said no. It was a firm no. It took years and years and years to develop those relationships with the payers to the point where they would be willing to contract or credential you. And the awareness of the market. The awareness in the market of oral appliance therapy is a tremendous opportunity. So you need to write these things down for yourself. Don't take these. These are just examples. You have to write this down for yourself. You have to figure out, in your specific market, what your strengths, weaknesses, opportunities, and threats are. Maybe the threat is the lack of physician support for oral appliance therapy. Maybe it's the inability to control the patient pathway, as I was mentioning before. You're screening. You're sending your patients over to the physician for diagnosis, and they're putting the patient on CPAP. And you can't control that process. And there are so many different services now that offer ways around that issue, whether it's home sleep testing, telemonitoring, or telemedicine, et cetera. And the low to no insurance reimbursement can be a major threat in the market as well. The other one I want to show you is a simple competitive analysis. And this is something that you can do. I mean, you can call around to look at your local sleep labs. It should really be a market analysis rather than competitive analysis. Your local sleep labs. The dentist in your area doing dental sleep medicine. The physicians that provide evaluation and management. You want to go around, and here are some simple things that you can ask in your local market. They've been valuable to me as I go into practices and I try to get an understanding of the landscape. It's just simple contact information of the entity itself, address, phone, fax, email. Who's the administrator? What services are they providing? Are they providing PSGs and HSTs, evaluation and management? What treatments? Pap, oral appliance therapy, surgeries? What insurances do they accept? If it's a sleep lab, who are the interpreting doctors that interpret out of there? Who's the medical director? What doctors refer to that testing facility? What are their hours? How many beds do they have? How many patients can they even possibly see? Who are the main contacts? What's their contact information? And what are the number of studies that they do? This is going to give you a really good sense of your local market. These are the questions to be asking. And specifically, that piece on who's referring. You can start at a sleep lab going in. If you understand who's referring into that sleep lab, then you know who to go market to, who to talk to about what you're providing. The other tool is a simple payer analysis. On this payer analysis, again, it's just the contact information, things that you really want to know about. What's the reimbursement? What's the reimbursement for the various services that are being provided? The oral appliance, so E0486, the office visits that you might be providing. So your new patient office visits, your 99201s to 204s, whatever level of coding you're comfortable with, whether that's billing based on time or based on complexity. Any type of imaging that you might be doing. Those are also things to be asking. And then the percentages in that local market. This is a huge one. In order to do a true financial analysis, you need to know what percentage of your local market a particular payer has. So how many lives they're covering out of the total lives. So we're going to go into that a little bit later. You also need to know the medical policy and whether or not that particular payer requires PDAC appliances only. How many days for reimbursement. As an example, in Illinois, we have payers that pay 30 to 45 day terms. And then you have the state of Illinois. And the state of Illinois, if you're working with the state of Illinois, as you know, our governors go straight from the governor's mansion to jail. The state of Illinois has no funding. And you might get paid in two years, if you're lucky, if you're working with public aid. So these things can play a factor as to whether or not you want to credential and whether or not you want to contract with a particular payer. You need to understand specifically the percentage of the market. But these other things are important as well. So I sort of laid them out for you. Hopefully you can use this and it's beneficial for you. So what are some of the pros and some of the cons of contracting? Obviously, you have a shorter payment term if you are in-network versus out-of-network. You can provide some consistent quota benefits for your patient, a faster authorization service, reduced patient out-of-pocket costs. That's in their co-insurance and on their deductible side. If the patient's in-network, it can be ranged from 10% to 20%. Out-of-network can be 30%, 40%. The out-of-network deductibles, you can go from an in-network of $1,000, $2,000 to $3,000, $4,000, $5,000 out-of-network. So there's a huge difference in terms of in and out-of-network from that sense in terms of the patient out-of-pocket costs. Increased patient acceptance, obviously. Many of you who are presenting to patients, if you're in a cash model, as Dr. Murphy mentioned, you might have to see five patients for one of them to accept. On an out-of-network basis, it's going to be similar unless you can get a gap approved. And on an in-network basis, more and more patients tend to accept the treatment. You have consistent reimbursement with a payer fee schedule. You have a contracted allowable rate. Reduced time to treatment is a huge one. All of these things take time, the authorization process, getting paid, et cetera. So the reduced time to treatment is a huge motivator. And the reduced AR. I think when we started, we were out-of-network. We'd submit claims. We were in a non-solicited status with Blue Cross Blue Shield of Illinois. And if someone came in who was from out-of-state, let's say they had Blue Cross of Texas or Blue Cross of Arkansas, it would not process at the rate that Blue Cross Blue Shield of Illinois would pay. And typically, they would just see us. They didn't even recognize the non-solicited status. So these claims would just sit out there for eons and eons. We wouldn't get paid. We wouldn't get paid the amounts we were supposed to get paid. Quoting patients was a nightmare. We had enormous insurance AR. And we didn't want to turn it over to the patient. We didn't feel that they were responsible for the bill. We had quoted them that they would have coverage. And so we were left with this massive accounts receivable. So the cons is that there's no balanced billing on an in-network side. You're accepting the insurance allowed. You are reliant on insurance. I've got a model. It's five brick-and-mortar facilities. We do full in-network. And it is 100% reliant on insurance. And if they lower that reimbursement, it's going to hurt. And it's going to hurt hard. So the lower reimbursement in-network is also a con. Typically, on the out-of-network side, you can charge what you charge. On the in-network side, it's going to be a lower rate of reimbursement. But you have all these pros to doing it. So I left you a little chart. I don't want you to look at this. You're going to get ill. But at the end of the day, take a look at this chart in the slides. The idea here is that you sort of circle your level of expertise in each of these attributes. Maybe it's practice sleep experience. If it's low, you circle here. Insurance experience, low, circle here. The dentist, sleep education, low. And you're going to get a sense after you circle a few of these, maybe the model that's right for you starting out. If you have no experience, charging cash is an easy thing to do. It's black and white. You have a rate that you explain that rate to patients. And they either accept it or they don't accept it. Simple as that. There's no need to get into the complexities of insurance coverage, quoting patients, et cetera. But you have to understand that if you go down that market path, you're going to have a little more reliance on your screening, a little more reliance on marketing to drive in patients. But you're not going to have any AR. That's nice. So I was talking about a payer mix. I was talking about understanding the percentage that a payer has in a particular market. This is crucial to understanding the financial reality of whether you go in or out of network. So these payer percentages, this is just a sample. It's not any particular state. So we have Blue Cross here in this example, Tricare, Cigna, Medicare, Medicaid, United, Humana. And they all have different percentages of the market in terms of the lives that they cover in a particular state. I've included a link for you. So you can go to this link and find the payer mix of the private insurance, the top private insurance companies within your state. And then you can go to another link that I provided and find the government plans and the percentage that they have in terms of your local state. Once you have that, you know your payer mix. Once you know your payer mix, the next step is to figure out the reimbursement by each payer. And you take those codes within that 90-day global, and you add them together. And that's going to get you a unit reimbursement by payer. So in this example, E0486 pays out at $1,600. They're including an initial office visit with the patient and the imaging that they're billing for a pen. And the total unit reimbursement is $1,745. Now, there are certain payers that don't pay for office visits. They don't pay for imaging. So you take those things out. And you also have to keep in the back of your mind, now, that every time somebody comes and sits in your chair, if you have a global contract, that's a hit. That's a financial hit for you. It's not a reimbursement, it's not a moneymaker. It's going to come off the bottom line. So after you have your unit reimbursement, you need to figure it by payer. You need to figure out the average unit reimbursement. If you're going to contract with a variety of payers, you need to pull this into your equation. So you take the unit reimbursement that I showed you from the previous slide, and you add those values for each payer together, multiply by the percentage of that particular payer, and you're going to get an average number. And in this example, it turned out to be $1,729. So the question that I'm always asked is, is dental sleep medicine profitable? Should I go in, network? I have no idea for you, specifically. I don't know your practice. I don't know the payers in your area. I know the payers in Illinois. I know our practice. I know our costs. I can't answer these questions for you, so I'm trying to give you some tools to answer them for yourself. And there are companies out there that are happy to credential you and get you contracted with a payer, and they don't know for you, either. They have no idea whether this will be profitable for your specific practice. So this is something you need to do on your own. I'm going to give you a very rudimentary formula to try at home. You plug in your own numbers. This is just an example. So we want to calculate the total hours of chair time. You have five chairs, 200 days that those chairs are in operation for eight hours a day. That's 8,000 chair hours. You take your total production. Maybe in your practice, you make $1 million a year. You take the total chair hours, and you divide those numbers, and you get $125 in this particular example. So you divide a million by 8,000. That comes out to $125 per chair hour. You calculate the total cost per year. Maybe in your practice, your total costs at the end of the year are $500,000 out of that $1 million. You take the $500,000, and again, you divide it by your 8,000 chair hours. You're going to get $6,250 per hour, per chair hour. You take the total production per hour, per chair hour, minus your total cost per chair hour. That gives you your total profit per chair hour. Then we calculate that average unit reimbursement. Or you can even do it if you're evaluating a single payer rather than all the payers at one time. You can do the unit reimbursement by payer. Or again, if you're evaluating the whole market, you're going to contract with every single payer in your area. You do that average unit reimbursement. And let's take out some costs in dental sleep medicine that we know. Let's say that your lab cost for your oral appliance is going to be $450 per unit. The sleep advertising cost for each patient that accepts treatment, let's say, is $400 in your practice per patient. Medical insurance expense, if you're going to be working with an outside billing company, let's say that's $200. And then you have the cost of gathering all the documents and so forth, which is a little unique to dental sleep medicine over general dentistry. Let's say that's $50 per patient. In our practice, we've analyzed the time that it takes to produce an oral appliance within that 90-day window. I'd say it's a safe bet to use three hours of your chair time for each patient that comes in for an oral appliance within that 90-day global fee that we're talking about here. So in this instance where the cost was $62.50 multiplied times 3, that's $187.50. So your total profit is $441 in this example. Divided by the three hours that it takes, that's $147 per hour. Now, if you go back, your profit in general dentistry was $125 per chair hour. So in this example, dental sleep medicine is producing more than your regular general dentistry per chair hour. And this is the equation that you need to look at so that you understand whether you're taking a financial hit doing dental sleep medicine or whether it's a potential moneymaker for your practice. I've seen too many people make the mistake of going into a market, getting into an insurance network, and then realizing that it doesn't make money for their practice, and then falling off. Over 95% of the people that got started in dental sleep medicine who ordered an initial appliance with some of the big manufacturers never reordered. So it's these type of metrics and the lack of due diligence on this end that creates that problem. So I'm hoping to avoid that for you and hoping to avoid a bunch of costs. So hopefully you can use those tools and answer some of those questions. I want to look at efficiency real quick. And after that, I'll open it up to some questions. These are some of the things that have worked really well for our practice over the years and have really moved the needle on cost or time. In terms of our patient care coordination department, and our coordinators, using the EMR, using that integrated digital faxing is a huge, huge time saver. Every fax that comes into the practice goes into a digital fax inbox. And then the documents are assigned to the specific patient and or the specific coordinator that's going to be handling whatever issue it is that's coming in. We have letter templates. A lot of people talked about their various letter templates, but the mail merge feature of taking the patient in the EMR and putting it right into that letter template saves a ton of time. And then we can just fax out whatever that letter is to the referring physicians. So communication with our physicians is always at the top of mind. These are some of the tools that make that communication a lot more efficient. Electronic signatures, I had sort of mentioned that that's been a huge disruptive area. this was a huge time saver for us. One of the things that I look at in the practice that I've been really focused on lately is what I call a DSO or a day sales outstanding. And what I'm looking at is the time that it takes between our new patient evaluation and our delivery appointment. So I'm looking at every factor in the practice that is lengthening that period of time. How long the labs take to make the device. How long does it take us to send things out to insurance and get it back and get an approval back? How long is it taking patients to schedule? Maybe you have a scheduling issue, we don't have enough open hours and days to get the patient in in a timely fashion. All of those things. But one of the biggest things that impacted that, and the reason I'm so focused on that, it's the number one complaint. Above all in dental sleep medicine, it's the time to treatment that is the number one complaint. The patient comes in, they get evaluated by our doctor, and they don't seem to understand no matter how much we reiterate it, how long it's going to take for that appliance to be in their hand and get it delivered. So we're trying as best as we can to reduce down the number of days that it takes us. And these CAD CAM devices have been a huge, huge in terms of time savings. We can scan, we can send out that case the same day. That is a huge change. It used to be the mail. So we would have all sorts of issues with things going in the mail, getting lost, whatever. It's a huge transformation. But electronic signatures, that allows us to send all the patient documentation to the patient before they even walk in the door. They can evaluate our release and receive, sign off on it, and then we can start the process of gathering all the medical documentation before they ever even walk in our door. That way we have their sleep study, we have their detailed written order from their referring provider. We have all the, everything we need to see that patient and get the case processed and out to the lab as fast as humanly possible, is ready to go due to these electronic signature technologies. And then interoperability. We talked a little bit about it. Dr. Mogel talked about this P2P open network and the ability for him to go in and communicate directly with his referring physicians. Some of these EMRs take that a step further where we can actually go into the EMR or the referring physician and grab whatever it is that we want so long as there was an order from that referring physician for the patient. So that's a huge time saver. In our insurance department, our insurance supervisor handles claims. Electronic claim submission, electronic remittance advice, electronic payment posting. These are things that save tremendous time. We used to get, you know, physical EOBs by paper and my insurance supervisor would be typing in, you know, $50 into so-and-so's account and go into the next account, $100 into so-and-so's account. This stuff all happens in an automated way now. We receive electronic remittance advice. We have electronic posting goes throughout our entire EMR and posts the payment to each particular patient's account. We have electronic funds transfer from the payer directly to our checking account. So the money is going in quicker. Electronic patient statements. We're not having to send out a physical statement to the patient. It can either be emailed or our clearinghouse can send out a physical copy. So that's a huge time saver. We used to be stuffing envelopes, licking them, putting them in the mail, putting a stamp on them. You know, it took a whole bunch of time. You know, this whole revenue cycle automation process really saves a lot of time. We're able to put in rules into our EMR to check claims and minimize errors before they go out so we don't have any issues with getting payment. Our benefits coordinator can check eligibility within our EMR at the click of a button. We click a button, we know co-pay, co-insurance for the various modalities of service, whether it's office visits, DME, imaging, et cetera, done in a heartbeat. And when you're seeing 50, 60 new patients a day, you know, it's imperative that you're able to check these benefits in a timely manner. We have referral task management programs that help us get HMO authorizations and manage that entire process. EMRs are designed for these workflows. Dental systems are not designed for these workflows. There are companies out there that make billions of dollars in this particular space and they're investing millions and millions of dollars into these technologies. We have a medical necessity coordinator who's able to work with various PDFs, collate documents, fax them out digitally. They have authorization management tools. These tools are an imperative. On our clinical department side, the CAD CAM appliances, as I mentioned, I did that clinical research for the American Academy of Dental Sleep Medicine in 2014 and won the clinical research award. And it was related to the selection of devices. We looked at problems and re-deliveries of appliances by appliance type. So a problem in our practice is anything that couldn't have been resolved over the telephone. And then a re-delivery is when a patient comes in, they go to get delivered, the device doesn't fit and we have to send it back to the lab and then schedule them for a re-delivery. So we looked at those rates and we looked at them by appliance. And I can tell you, if you are not tracking which appliances have the most problems and which appliances have the most re-deliveries, you're doing yourself a tremendous disservice. The largest cost savings by far that you're going to see in your practice is related to that issue. You need to track it. I could tell you what works in our practice, but you need to track it for your own practice and find out what works within your practice specifically. You need to track the number of days that devices are out to the labs, et cetera. The digital workflow has transformed what we do. We use things like the Matrix within our practice. We don't use it for everyone, only with labs that have purchased, you know, sleep labs that have purchased that equipment outside of our practice who want to work with us in that regard. And patients will come in to us, we'll fit them with Matrix Trace, send them out. They're either determined to be a responder, non-responder, and then we can move on to oral appliance therapy or combination therapy. As I said, we provide CPAP. We provide oral appliance and CPAP used at the same time, combination therapy, or oral appliance fused to CPAP, hybrid therapy, getting rid of the mask, the straps, or sorry, getting rid of the straps, movement of the mask, air leakage, that type of thing, reducing pressures. Staff doing their own adjustments, it's a tremendous, tremendous time saver. You need to train your staff. We talked about, you know, micromanagement. You need to be able to delegate to make it more efficient. And physician referrals is a huge transformation. I heard a lot of people talking today about their marketing and their screening. I can tell you one of the most transformative decisions in our practice was to market specifically, to patients who are intolerant, non-compliant, or refuse CPAP. They have already been diagnosed. They already have obstructive sleep apnea, and they are ready to go. Or you can pay all this money and market to people who have never been diagnosed, and maybe, maybe they'll accept treatment, or maybe you'll screen them, you'll refer them off to your local sleep physician, and he'll put them on CPAP for you after you've spent all this money trying to bring patients into your practice. So remember that, but also remember, and I'll tell you, one of the biggest mistakes I ever made was to market in such a way that was somewhat negative to CPAP. You know, when I would go into physician practices, they pulled out our newspaper article, and they would say, is this you guys? And I'd say, yeah, and they would show me the door. So be careful about how you advertise. Standardized workflow, transparent policies and procedures, these are imperative so your entire team is on the same page. That EMR-capable payment posting, this has been transformative for our clinical assistants. They scan a card, the payment goes right into the system, and posts to the patient's account. Using portals, entering in and data entering documentation for your clinical personnel or your administrative personnel is a nightmare. It takes a ton of time. You know, when you're looking or evaluating EMRs, you want to find something that has a portal, that has the capability of doing questionnaires, and those questionnaires need to go right into your progress note. If they don't, the whole thing is worthless. The whole idea is it's a time saver for your team. And this digital intraoral scanning, it is a game changer. I mean a game changer. We use three-shape trios, and I wouldn't go anywhere else. It is super fast and super accurate, and I can tell you when we track appliances and we track what works and what doesn't, I know the number of problems and re-deliveries have gone way down. And they have gone way down with CAD CAM devices, with devices that are printed, and devices that are milled. They are far more accurate, and we have far fewer issues, far fewer patient complaints down the line. So huge changes there. On my side, you know, I'm in charge of the business development of the practice, so the CRM system that I use, that's a customer relation management tool. Office 365 for our email, SharePoint, which is, you know, houses a lot of our office documents and so forth. And then our EMR reporting. If you don't have an EMR that can report on your financial data, your clinical data, you are operating blind. You are not using those metrics as we discussed earlier. You know, provide professional employer organizations that handle human resources issues and benefits. Those things have been a lifesaver. We've been able to push those responsibilities off to someone outside of the practice who is an expert in that area. We personally use ADP. It's been a great service for our practice. Clinical automation rules, things that look for common errors that our staff make in documentation, looking at vitals and flagging it if staff don't put it in. So those are very helpful. And the clinical reporting that we do. You know, we couldn't document whether these devices were working well for us or not if we weren't able to get into the metadata within the EMR and report on what was working and what wasn't working. I hope this was helpful. I really appreciate everybody having me here. Good luck. Thank you. handle that with patients, or do you not experience that? They absolutely are held to the exact same standards. I mean, I think one of the advantages of CPAP over an oral appliance is that it's on a rental fee schedule. So typically, the cost of the CPAP machine is spread out over the course of 13 months. So they're billing small increments month after month. And maybe patients just aren't used to it. Maybe they're not realizing that the small bill that's coming every month. Are you saying that the patients, instead of having to put a bulk of money down initially, they're paid? Because I know that the DME companies get paid over 13 months. So what you're telling me is that if the patient was being charged $130 for the CPAP, they'd get a bill for $10 a month? Yeah. So that could be one area. And or the DME company. scheduling are you doing your scheduling since you have five offices out of a central center for all your offices or how do patients contact if if how does the patient How do you get appointments to your remote centers? So we have a central scheduling. We have a corporate office that has all of our administrative personnel. So that patient care coordination department that I was mentioning, that's in the corporate office. Our management team is in the corporate office. And everyone on our billing side is in that corporate office as well. So that's all handled. You know, any phone call that comes into the practice is coming to that corporate location. When I first started, we were chair side. We were picking up the phone and sitting there having a new patient consult at the same time trying to explain the financial reality to the patient. It was a nightmare. The phone was ringing constantly from our advertising and it was very disruptive to the clinical environment. So we pulled it to a corporate location. So how do you? So great question. Again that EMR is central to that process. So it allows for central scheduling and we're able to schedule appointments by appointment type. I think that isn't talked about enough. We have all kinds of appointment types that are in our EMR. So it might be a new patient appointment, a new patient delivery appointment, a problem appointment. So in the instance where somebody has an issue, we're going to schedule a problem appointment. It's going to be a 30 minute appointment and the central scheduler is going to put what that problem was in the appointment window. So when that patient comes in to whatever remote clinic they're going into, immediately the provider's alerted to the fact that this patient's coming in for a problem appointment and they know what that issue is. With all the different marketing you do, what had the best return on investment? Well, you know, there was the previous way that we did things and there's the way that we do things today. So we used to do all this marketing. Today, when I say that we're nearly 100% referred, I mean I don't do any marketing, none. No direct consumer marketing whatsoever. So what was effective in 2007 isn't necessarily going to be effective now. So I think, you know, what is effective now for us is the relationship building. And that whole idea of cost, access, and quality is about the relationships. It's about the relationships with the stakeholders. We're looking to break down barriers at the level of the payer, at the level of the patient, at the level of the referring provider. So I'm out speaking to those people working through those issues. That's the relationship development. You know, it's not about our EMR. There are many different EMRs that are out there. I wouldn't say that ours is the best. And I wouldn't say that if I evaluated them now that I would go with our EMR. So I don't want to advise you on a specific EMR. What I want to advise you on is the fact that EMRs in general and a practice management system, and they have to have both, electronic medical record and practice management system is what is important. And you have to look at them all, and you have to see which one you feel is most valuable for your particular practice situation. As general dentistry has become very corporate. I have tons of patients and I think they're going to look at the same numbers that I presented. You know, it's 12 to 25 percent of their patient base is going to have obstructive sleep apnea. There's a potential to keep the patient within their practice and provide value to the patient. I think right now there are some significant barriers for a conglomerate dental sleep, you know, a conglomerate DSO to get involved in dental sleep, but it's going to happen. Sure, the trays themselves, you know, I think Zephyr, I mean, this, the way that we do it is obsolete at this point. Zephyr has killed the in-lab matrix program and I think the value or that value proposition that I was talking about was specifically a value proposition for the sleep lab and sleep physician. We, it was to a degree for the patient as well. We could fit the patient for those trays, send them over to the sleep lab, you know, and it ensured that the patient had a sleep test. It ensured that we had an efficacy test to know whether or not the patient was a responder to mandibular advancement before they went on to an oral appliance and it gave us a good idea of where the protrusion should be. So in that sense, it was a moneymaker for the sleep lab. When you look at the number of studies that they were doing as opposed to the fallout of patients, if you do it the traditional way of providing the custom device first, it was, it was a big deal to them, but the cost, you know, to the patient were the trays that was out of pocket for the patient, it was about $100, $125, somewhere in there, and then they had the sleep test at the end. Tell us about your quality assurance program. What do you, what do you measure, how often, and why? Great question. We're measuring patient satisfaction. We do that on a quarterly basis. We have measures that are sort of directed by the AADSM per our accreditation. Risk to patient for falls. We're a DME company. So yeah, we have to monitor these things I think more importantly the tracking That we really need to be looking at is looking at what happens when a patient is referred over Where do patients fall out in the process? So if you're doing it yourself a simple Excel spreadsheet Track all the patients that come in. Who are they referred from? What happened along the way did they make it to the new patient appointment? If not, what happened and then you get an understanding of where patients are falling out right off the get-go When they got to the new patient appointment, how many patients fell out between that point and delivery from delivery? How many patients actually were made it to the one month follow-up and of those patients? How many people did you refer out for a sleep study? And how many had that study? There is equal fall-off and I will repeat it there is equal fall-off in oral appliance therapy as there is with CPAP and It would be a disservice to yourself and your patients to not realize that we will have side effects we will have patients that drop off a therapy and Ultimately, I think when you look at some of the newer data that was just published in the Journal of Dental Sleep Medicine it's a 10-year follow-up a tremendous number of patients fell out of that study at 10 years when you look at the Orcades data it Was like 300 and some odd patients only 52% of them were left on therapy at the end of five years That's why we need many different treatment options It's got to be the oral appliance oral appliance and CPAP oral appliance and positional devices Phillips has got a great new product for positional therapy and it's many other things surgery. Maybe it's palatal expansion There's a lot of new data that suggests that that's possible for definitely for pediatric patients But potentially for some adult patients as well With procedures like dome and marpy. There is some good clinical We charge them separately. So we charge for a new patient appointment, we charge for imaging, and then once we bill the oral appliance, the fees are included for that global period, 90 days. So there's no charges for that period of time, but there is a charge before and then after 90 days there are charges for follow-up. Okay, that's all the time we have. Scott, that was fantastic. Thank you so much.

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