getting paid for paps Re: Re: Solo advice

[Guest guest]

So, what cpt are folks using if someone comes in just for pap/breast exam?In order to get paid, I started using a 99214 and then using the icd-9s

V72.31/V76.10.It was going fine and I was satisfied that the payment was

reasonable for the appointment.But, just recently a patient with a

high-deductible plan reported that the appt should have been billed differently so

she would not have to pay out of pocket and have it added to her deductible. The

insurance company would pay for preventive care ... I guess the ICD-9 codes aren't

sufficient and don't make the issue obvious! (sorry for sarcasm).So,

what do folks use for private insurance when it's just a pap/breast appt?Any

help with this is greatly appreciated.Tim

Wayne,

I agree with you 100%. I am going to stop doing GYN exams as well because I am tired of not being paid for them. Most of the big insurers in my area bundle the GYN exam with the rest of the annual exam fee. I have begged, I have pleaded and I have cursed but nothing changes. I do not do Paps on men and I get the same reimbursement for their annual exams as I do for the women on whom I do

Paps and I do not have to collect specimens, clean and sterilize equipment,

review test results and call men about their results. So, from now on,

most of my women will just have to take another day off work and go to a gynecologist and pay another copay to get their Paps done. I am done.

Solo advice> > I need some advice. I am opening my cash-only practice in January and given the economy > am realistic about how fast it will grow. I am absolutely convinced it can be successful, but > the ramp up will surely be slower than it would have been a couple of years ago. Therefore, > I'm getting very serious about controlling overhead so I can make it through the lean months, > and perhaps years, it

will take to get the practice where it needs to be. I've not been overly > excited about practicing with no support, but the

economic realities may force that decision. > So the

question - how can a male provider realistically practice solo-solo without

a > chaperone available for gyn exams, or focused cardiac exams for

that matter? How are > others solving this? > >

Thanks -> > Chad Costley>

chadcostley@... > > > ------------------------------------> > Yahoo! Groups Links> > > > http://docs.yahoo.com/info/terms/>------------------------------------Yahoo! Groups Links To visit your group on the web, go to: http://groups.yahoo.com/group// Your email settings: Individual Email | Traditional To change settings online go to: http://groups.yahoo.com/group//join (Yahoo! ID required) To change settings via email: mailto:-digest

mailto:-fullfeatured

[Guest guest]

OK,

So here is a small rant. How stupid is

this? Why do we need to cloud our minds with all this insanity? As we move

toward a different system, I for one would love to see a payment where I get

one amount of money for every visit regardless of complexity. Patient shows up

in the office, I get $50 or $75 or whatever (combined with a

per member per month rate based on patient satisfaction with the office

(ex. HYH results)). Simplifying the payment system would immediately eliminate

a HUGE amount of administrative stuff which greatly increases the overall

costs. Make it simple, allow me to focus on my patient not on stupid codes

which change with the winds.

getting paid for paps Re:

[Practiceimprovemen t1] Re: Solo advice

So, what cpt are folks using if someone comes in just for pap/breast exam?

In order to get paid, I started using a 99214 and then using the icd-9s

V72.31/V76.10.

It was going fine and I was satisfied that the payment was reasonable for the

appointment.

But, just recently a patient with a high-deductible plan reported that the appt

should have been billed differently so she would not have to pay out of pocket

and have it added to her deductible. The insurance company would pay for

preventive care ... I guess the ICD-9 codes aren't sufficient and don't make

the issue obvious! (sorry for sarcasm).

So, what do folks use for private insurance when it's just a pap/breast appt?

Any help with this is greatly appreciated.

Tim

Wayne,

I agree with you

100%. I am

going to stop doing GYN exams as well because I am tired of not

being paid for

them. Most of the big insurers in my area bundle the GYN

exam with the

rest of the annual exam fee. I have begged, I have pleaded

and I have

cursed but nothing changes. I do not do Paps on men and I get

the same

reimbursement for their annual exams as I do for the women on whom I do

Paps and I do

not have to collect specimens, clean and sterilize equipment,

review test

results and call men about their results. So, from now

on, most of my

women will just have to take another day off work and go to a

gynecologist

and pay another copay to get their Paps done. I am

done.

[Practiceimprovemen t1] Solo advice

>

> I need some

advice. I am opening my cash-only practice in January and given the

economy

> am realistic about how fast it will grow. I am

absolutely convinced it can be successful,

but

> the ramp up will

surely be slower than it would have been a couple of years ago.

Therefore,

> I'm getting very serious about controlling overhead so

I can make it through the lean

months,

> and perhaps years, it will

take to get the practice where it needs to be. I've not been

overly

> excited about practicing with no support, but the economic realities

may force that

decision.

> So the question - how can a male

provider realistically practice solo-solo without a

> chaperone

available for gyn exams, or focused cardiac exams for that matter? How

are

> others solving this?

>

> Thanks -

>

>

Chad Costley

> chadcostley@ ...

>

>

>

------------ --------- --------- ------

>

> Yahoo!

Groups Links

>

>

>

> http://docs.

yahoo.com/ info/terms/

>

------------ --------- --------- ------

Yahoo!

Groups Links

To visit your group on the web, go to:

http://groups.

yahoo.com/ group/Practiceim provement1/

Your email settings:

Individual Email |

Traditional

To change settings online go to:

http://groups. yahoo.com/ group/Practiceim provement1/ join

(Yahoo! ID required)

To change settings via

email:

mailto:Practiceimprovement

1-digest@ yahoogroups. com

mailto:Practiceimprovement

1-fullfeatured@ yahoogroups. com

[Guest guest]

OK,

So here is a small rant. How stupid is

this? Why do we need to cloud our minds with all this insanity? As we move

toward a different system, I for one would love to see a payment where I get

one amount of money for every visit regardless of complexity. Patient shows up

in the office, I get $50 or $75 or whatever (combined with a

per member per month rate based on patient satisfaction with the office

(ex. HYH results)). Simplifying the payment system would immediately eliminate

a HUGE amount of administrative stuff which greatly increases the overall

costs. Make it simple, allow me to focus on my patient not on stupid codes

which change with the winds.

getting paid for paps Re:

[Practiceimprovemen t1] Re: Solo advice

So, what cpt are folks using if someone comes in just for pap/breast exam?

In order to get paid, I started using a 99214 and then using the icd-9s

V72.31/V76.10.

It was going fine and I was satisfied that the payment was reasonable for the

appointment.

But, just recently a patient with a high-deductible plan reported that the appt

should have been billed differently so she would not have to pay out of pocket

and have it added to her deductible. The insurance company would pay for

preventive care ... I guess the ICD-9 codes aren't sufficient and don't make

the issue obvious! (sorry for sarcasm).

So, what do folks use for private insurance when it's just a pap/breast appt?

Any help with this is greatly appreciated.

Tim

Wayne,

I agree with you

100%. I am

going to stop doing GYN exams as well because I am tired of not

being paid for

them. Most of the big insurers in my area bundle the GYN

exam with the

rest of the annual exam fee. I have begged, I have pleaded

and I have

cursed but nothing changes. I do not do Paps on men and I get

the same

reimbursement for their annual exams as I do for the women on whom I do

Paps and I do

not have to collect specimens, clean and sterilize equipment,

review test

results and call men about their results. So, from now

on, most of my

women will just have to take another day off work and go to a

gynecologist

and pay another copay to get their Paps done. I am

done.

[Practiceimprovemen t1] Solo advice

>

> I need some

advice. I am opening my cash-only practice in January and given the

economy

> am realistic about how fast it will grow. I am

absolutely convinced it can be successful,

but

> the ramp up will

surely be slower than it would have been a couple of years ago.

Therefore,

> I'm getting very serious about controlling overhead so

I can make it through the lean

months,

> and perhaps years, it will

take to get the practice where it needs to be. I've not been

overly

> excited about practicing with no support, but the economic realities

may force that

decision.

> So the question - how can a male

provider realistically practice solo-solo without a

> chaperone

available for gyn exams, or focused cardiac exams for that matter? How

are

> others solving this?

>

> Thanks -

>

>

Chad Costley

> chadcostley@ ...

>

>

>

------------ --------- --------- ------

>

> Yahoo!

Groups Links

>

>

>

> http://docs.

yahoo.com/ info/terms/

>

------------ --------- --------- ------

Yahoo!

Groups Links

To visit your group on the web, go to:

http://groups.

yahoo.com/ group/Practiceim provement1/

Your email settings:

Individual Email |

Traditional

To change settings online go to:

http://groups. yahoo.com/ group/Practiceim provement1/ join

(Yahoo! ID required)

To change settings via

email:

mailto:Practiceimprovement

1-digest@ yahoogroups. com

mailto:Practiceimprovement

1-fullfeatured@ yahoogroups. com

[Guest guest]

OK,

So here is a small rant. How stupid is

this? Why do we need to cloud our minds with all this insanity? As we move

toward a different system, I for one would love to see a payment where I get

one amount of money for every visit regardless of complexity. Patient shows up

in the office, I get $50 or $75 or whatever (combined with a

per member per month rate based on patient satisfaction with the office

(ex. HYH results)). Simplifying the payment system would immediately eliminate

a HUGE amount of administrative stuff which greatly increases the overall

costs. Make it simple, allow me to focus on my patient not on stupid codes

which change with the winds.

getting paid for paps Re:

[Practiceimprovemen t1] Re: Solo advice

So, what cpt are folks using if someone comes in just for pap/breast exam?

In order to get paid, I started using a 99214 and then using the icd-9s

V72.31/V76.10.

It was going fine and I was satisfied that the payment was reasonable for the

appointment.

But, just recently a patient with a high-deductible plan reported that the appt

should have been billed differently so she would not have to pay out of pocket

and have it added to her deductible. The insurance company would pay for

preventive care ... I guess the ICD-9 codes aren't sufficient and don't make

the issue obvious! (sorry for sarcasm).

So, what do folks use for private insurance when it's just a pap/breast appt?

Any help with this is greatly appreciated.

Tim

Wayne,

I agree with you

100%. I am

going to stop doing GYN exams as well because I am tired of not

being paid for

them. Most of the big insurers in my area bundle the GYN

exam with the

rest of the annual exam fee. I have begged, I have pleaded

and I have

cursed but nothing changes. I do not do Paps on men and I get

the same

reimbursement for their annual exams as I do for the women on whom I do

Paps and I do

not have to collect specimens, clean and sterilize equipment,

review test

results and call men about their results. So, from now

on, most of my

women will just have to take another day off work and go to a

gynecologist

and pay another copay to get their Paps done. I am

done.

[Practiceimprovemen t1] Solo advice

>

> I need some

advice. I am opening my cash-only practice in January and given the

economy

> am realistic about how fast it will grow. I am

absolutely convinced it can be successful,

but

> the ramp up will

surely be slower than it would have been a couple of years ago.

Therefore,

> I'm getting very serious about controlling overhead so

I can make it through the lean

months,

> and perhaps years, it will

take to get the practice where it needs to be. I've not been

overly

> excited about practicing with no support, but the economic realities

may force that

decision.

> So the question - how can a male

provider realistically practice solo-solo without a

> chaperone

available for gyn exams, or focused cardiac exams for that matter? How

are

> others solving this?

>

> Thanks -

>

>

Chad Costley

> chadcostley@ ...

>

>

>

------------ --------- --------- ------

>

> Yahoo!

Groups Links

>

>

>

> http://docs.

yahoo.com/ info/terms/

>

------------ --------- --------- ------

Yahoo!

Groups Links

To visit your group on the web, go to:

http://groups.

yahoo.com/ group/Practiceim provement1/

Your email settings:

Individual Email |

Traditional

To change settings online go to:

http://groups. yahoo.com/ group/Practiceim provement1/ join

(Yahoo! ID required)

To change settings via

email:

mailto:Practiceimprovement

1-digest@ yahoogroups. com

mailto:Practiceimprovement

1-fullfeatured@ yahoogroups. com

[Guest guest]

Chad,

I agree and believe the cash only/retainer

fee practices are a great place to look for the future payment system as that

model really is far more of a “free market” model than anything dealing

with insurance. In other words, if docs believe this is how they should be paid

(and are happy with it) and patients feel they are getting a good deal for

their money (and are happy with it), then it seems a logical place to start.

Who knows, maybe someday we all will be paid in a way that makes sense and encourages

a good relationship with our patients. In my mind, that day cannot come soon

enough (by the way, I do take insurances, but do dream a lot).

> [Practiceimprovemen t1] Solo advice

> >

> > I need some

> advice. I am opening my cash-only practice in January and given the

>

> economy

> > am realistic about how fast it will grow. I am

> absolutely convinced it can be successful,

> but

> > the ramp up will

> surely be slower than it would have been a couple of years ago.

>

> Therefore,

> > I'm getting very serious about controlling overhead so

> I can make it through the lean

> months,

> > and perhaps years, it will

> take to get the practice where it needs to be. I've not been

> overly

>

> > excited about practicing with no support, but the economic realities

> may force that

> decision.

> > So the question - how can a male

> provider realistically practice solo-solo without a

> > chaperone

> available for gyn exams, or focused cardiac exams for that matter? How

> are

> > others solving this?

> >

> > Thanks -

> >

> >

> Chad Costley

> > chadcostley@ ...

> >

> >

> >

> ------------ --------- --------- ------

> >

> > Yahoo!

> Groups Links

> >

> >

> >

> > http://docs. <http://docs.yahoo.com/info/terms/>

yahoo.com/

> info/terms/

> >

>

>

>

>

> ------------ --------- --------- ------

>

> Yahoo!

> Groups Links

>

> To visit your group on the web, go to:

>

> http://groups. <http://groups.yahoo.com/group//>

> yahoo.com/ group/Practiceim provement1/

>

>

> Your email settings:

> Individual Email |

> Traditional

>

> To change settings online go to:

>

> http://groups. yahoo.com/ group/Practiceim

provement1/ join

> <http://groups.yahoo.com/group//join>

>

> (Yahoo! ID required)

>

> To change settings via

> email:

> mailto:Practiceimprovement

> <mailto:-digest >

1-digest@

> yahoogroups. com

>

> mailto:Practiceimprovement

> <mailto:-fullfeatured >

> 1-fullfeatured@ yahoogroups. com

>

>

>

[Guest guest]

Chad,

I agree and believe the cash only/retainer

fee practices are a great place to look for the future payment system as that

model really is far more of a “free market” model than anything dealing

with insurance. In other words, if docs believe this is how they should be paid

(and are happy with it) and patients feel they are getting a good deal for

their money (and are happy with it), then it seems a logical place to start.

Who knows, maybe someday we all will be paid in a way that makes sense and encourages

a good relationship with our patients. In my mind, that day cannot come soon

enough (by the way, I do take insurances, but do dream a lot).

> [Practiceimprovemen t1] Solo advice

> >

> > I need some

> advice. I am opening my cash-only practice in January and given the

>

> economy

> > am realistic about how fast it will grow. I am

> absolutely convinced it can be successful,

> but

> > the ramp up will

> surely be slower than it would have been a couple of years ago.

>

> Therefore,

> > I'm getting very serious about controlling overhead so

> I can make it through the lean

> months,

> > and perhaps years, it will

> take to get the practice where it needs to be. I've not been

> overly

>

> > excited about practicing with no support, but the economic realities

> may force that

> decision.

> > So the question - how can a male

> provider realistically practice solo-solo without a

> > chaperone

> available for gyn exams, or focused cardiac exams for that matter? How

> are

> > others solving this?

> >

> > Thanks -

> >

> >

> Chad Costley

> > chadcostley@ ...

> >

> >

> >

> ------------ --------- --------- ------

> >

> > Yahoo!

> Groups Links

> >

> >

> >

> > http://docs. <http://docs.yahoo.com/info/terms/>

yahoo.com/

> info/terms/

> >

>

>

>

>

> ------------ --------- --------- ------

>

> Yahoo!

> Groups Links

>

> To visit your group on the web, go to:

>

> http://groups. <http://groups.yahoo.com/group//>

> yahoo.com/ group/Practiceim provement1/

>

>

> Your email settings:

> Individual Email |

> Traditional

>

> To change settings online go to:

>

> http://groups. yahoo.com/ group/Practiceim

provement1/ join

> <http://groups.yahoo.com/group//join>

>

> (Yahoo! ID required)

>

> To change settings via

> email:

> mailto:Practiceimprovement

> <mailto:-digest >

1-digest@

> yahoogroups. com

>

> mailto:Practiceimprovement

> <mailto:-fullfeatured >

> 1-fullfeatured@ yahoogroups. com

>

>

>

[Guest guest]

I wholeheartedly agree but in considering how to move the system forward through change, one consideration for the "system" is that without coding, there is no data on disease statistics, morbidity etc... would you be willing to continue the current icd-9 coding system in EMRs for reporting purposes only? Perhaps mandatory reporting to some entity on a monthly basis? Maybe I'm off base, but as we re-design, I think we have to consider the full impact of change and how to offset some of the unintended losses.

Carla Gibson

Subject: getting paid for paps Re: Re: Solo adviceTo: Date: Wednesday, December 10, 2008, 4:37 PM

My addition to the rant...Exactly right. That's why cash-only practices with a blended membership and simple fee per visit model make sense. My approach is $80 per month covers virtual visits, 24 hour direct access etc. If you do need to be seen - a simple fee schedule - $40, $80 or $120 (complete physical including gyn if necessary) based upon time and complexity. Simple to understand, disincentive for overuse but appropriate reimbursement to the doc for things that in an insurance environment wouldn't be billable, no craziness. If someone needs an EKG - fine - we do it and we've already been compensated in the retainer or the visit charge. If someone needs a urinalysis - no stupidity about figuring out whether it's their diabetes ICD-9 code or their HTN ICD-9 code that needs to be linked to the test in order to get reimbursed. And back to the original subject of this thread, if a woman needs a gyn exam - you

do it because it's the right thing to do, without worrying about whether an insurance company is willing to carve it out of what would otherwise be defined as a complete physical under some crazy logic I don't care to try to understand. I remember when I was on faculty at Henry Ford Hospital in Detroit attending a Grand Rounds primarily focused on educating medical students and residents in which the entire talk was about how to be a good coder. I was disgusted. I couldn't believe we had lowered our educational mission to that point.Now the caveat. I recognize it's easy to preach about the virtue of cash-only, no-insurance practices when you're starting a practice in a city of 6 million people and you only need to convince a few hundred to make it work. Most doctors don't practice in areas like that, so I feel for those of you who have to struggle for your patients within the realm that almost drove me

away from clinical practice.But ...the answer to your question is "very stupid."Chad > >> > Don't do gyn > exams. When my sister stopped doing them, it really saved us alot of > > headaches. But I do understand that as cash only, you may want to > offer it--maybe as > part of the annual? We are trying to slowly > convert to cash only and are re-thinking the > issue.> > > > > > > > > > > > ____________ _________ _________ __> >> From: chadcostley > ...>> > To: Practiceimprovement <mailto:Practiceimprovement 1yahoogroups (DOT) com>> 1yahoogroups (DOT) com>

> > Sent: Tuesday, November 25, 2008 5:40:32 AM> > Subject: > [Practiceimprovemen t1] Solo advice> > > > I need some > advice. I am opening my cash-only practice in January and given the > > economy > > am realistic about how fast it will grow. I am > absolutely convinced it can be successful, > but > > the ramp up will > surely be slower than it would have been a couple of years ago. > > Therefore, > > I'm getting very serious about controlling overhead so > I can make it through the lean > months, > > and perhaps years, it will > take to get the practice where it needs to be. I've not been > overly > > > excited about practicing with no support, but the economic realities > may force that > decision. > > So the question - how can a male

> provider realistically practice solo-solo without a > > chaperone > available for gyn exams, or focused cardiac exams for that matter? How > are > > others solving this? > > > > Thanks -> > > > > Chad Costley> > chadcostley@ ... > > > > > > > ------------ --------- --------- ------> > > > Yahoo! > Groups Links> > > > > > > > http://docs. <http://docs. yahoo.com/ info/terms/> yahoo.com/> info/terms/> >> > > > > ------------ --------- --------- ------> > Yahoo! > Groups Links> > To visit your group on the web, go to:> > http://groups. <http://groups. yahoo.com/ group/Practiceim provement1/>> yahoo.com/ group/Practiceim provement1/> > > Your email settings:> Individual Email | > Traditional> > To change settings online go to:> > http://groups. yahoo.com/ group/Practiceim provement1/ join> <http://groups. yahoo.com/ group/Practiceim provement1/ join> > > (Yahoo! ID required)> > To change settings via > email:> mailto:Practiceimpr ovement> <mailto:Practiceimprovement 1-digest@ yahoogroups. com> 1-digest@> yahoogroups. com > > mailto:Practiceimpr ovement> <mailto:Practiceimprovement 1-fullfeatured@ yahoogroups. com>> 1-fullfeatured@ yahoogroups. com> > >

[Guest guest]

I wholeheartedly agree but in considering how to move the system forward through change, one consideration for the "system" is that without coding, there is no data on disease statistics, morbidity etc... would you be willing to continue the current icd-9 coding system in EMRs for reporting purposes only? Perhaps mandatory reporting to some entity on a monthly basis? Maybe I'm off base, but as we re-design, I think we have to consider the full impact of change and how to offset some of the unintended losses.

Carla Gibson

Subject: getting paid for paps Re: Re: Solo adviceTo: Date: Wednesday, December 10, 2008, 4:37 PM

My addition to the rant...Exactly right. That's why cash-only practices with a blended membership and simple fee per visit model make sense. My approach is $80 per month covers virtual visits, 24 hour direct access etc. If you do need to be seen - a simple fee schedule - $40, $80 or $120 (complete physical including gyn if necessary) based upon time and complexity. Simple to understand, disincentive for overuse but appropriate reimbursement to the doc for things that in an insurance environment wouldn't be billable, no craziness. If someone needs an EKG - fine - we do it and we've already been compensated in the retainer or the visit charge. If someone needs a urinalysis - no stupidity about figuring out whether it's their diabetes ICD-9 code or their HTN ICD-9 code that needs to be linked to the test in order to get reimbursed. And back to the original subject of this thread, if a woman needs a gyn exam - you

do it because it's the right thing to do, without worrying about whether an insurance company is willing to carve it out of what would otherwise be defined as a complete physical under some crazy logic I don't care to try to understand. I remember when I was on faculty at Henry Ford Hospital in Detroit attending a Grand Rounds primarily focused on educating medical students and residents in which the entire talk was about how to be a good coder. I was disgusted. I couldn't believe we had lowered our educational mission to that point.Now the caveat. I recognize it's easy to preach about the virtue of cash-only, no-insurance practices when you're starting a practice in a city of 6 million people and you only need to convince a few hundred to make it work. Most doctors don't practice in areas like that, so I feel for those of you who have to struggle for your patients within the realm that almost drove me

away from clinical practice.But ...the answer to your question is "very stupid."Chad > >> > Don't do gyn > exams. When my sister stopped doing them, it really saved us alot of > > headaches. But I do understand that as cash only, you may want to > offer it--maybe as > part of the annual? We are trying to slowly > convert to cash only and are re-thinking the > issue.> > > > > > > > > > > > ____________ _________ _________ __> >> From: chadcostley > ...>> > To: Practiceimprovement <mailto:Practiceimprovement 1yahoogroups (DOT) com>> 1yahoogroups (DOT) com>

> > Sent: Tuesday, November 25, 2008 5:40:32 AM> > Subject: > [Practiceimprovemen t1] Solo advice> > > > I need some > advice. I am opening my cash-only practice in January and given the > > economy > > am realistic about how fast it will grow. I am > absolutely convinced it can be successful, > but > > the ramp up will > surely be slower than it would have been a couple of years ago. > > Therefore, > > I'm getting very serious about controlling overhead so > I can make it through the lean > months, > > and perhaps years, it will > take to get the practice where it needs to be. I've not been > overly > > > excited about practicing with no support, but the economic realities > may force that > decision. > > So the question - how can a male

> provider realistically practice solo-solo without a > > chaperone > available for gyn exams, or focused cardiac exams for that matter? How > are > > others solving this? > > > > Thanks -> > > > > Chad Costley> > chadcostley@ ... > > > > > > > ------------ --------- --------- ------> > > > Yahoo! > Groups Links> > > > > > > > http://docs. <http://docs. yahoo.com/ info/terms/> yahoo.com/> info/terms/> >> > > > > ------------ --------- --------- ------> > Yahoo! > Groups Links> > To visit your group on the web, go to:> > http://groups. <http://groups. yahoo.com/ group/Practiceim provement1/>> yahoo.com/ group/Practiceim provement1/> > > Your email settings:> Individual Email | > Traditional> > To change settings online go to:> > http://groups. yahoo.com/ group/Practiceim provement1/ join> <http://groups. yahoo.com/ group/Practiceim provement1/ join> > > (Yahoo! ID required)> > To change settings via > email:> mailto:Practiceimpr ovement> <mailto:Practiceimprovement 1-digest@ yahoogroups. com> 1-digest@> yahoogroups. com > > mailto:Practiceimpr ovement> <mailto:Practiceimprovement 1-fullfeatured@ yahoogroups. com>> 1-fullfeatured@ yahoogroups. com> > >