Business Management | May 2020 Hearing Review

Survival tips and advice for emerging even stronger than before from Dan Quall, MS

Being proactive and focusing on those things that are controllable—as well as preparing your practice to succeed just as soon as conditions improve—is key for today’s small business owners.

By Karl Strom, editor

So, you own or manage a fairly prosperous practice. You’ve nurtured it through the years and you’re rightfully proud of the organization you’ve built. You’ve done very well.

Then disaster strikes. In this case, it’s Covid-19 forcing the radical scale-back of business and loss of revenues. But it could also have been a natural disaster, a sickness affecting you or your partner(s), or some other unforeseeable event. Cash flow—an ever-present concern and key performance indicator (KPI) even in good times—suddenly is reduced to a trickle or stops altogether.

What do you do?

Dan Quall, MS

Longtime hearing care practice management executive and audiologist Dan Quall, MS, recommends that first you take a deep breath, make certain you’re not making panicky decisions, and then create a plan remembering 2 of the 7 “habits” that author Steven Covey recommends for highly effective people: 1) Be proactive and control the controllable, and 2) Start with the end in mind.1

Quall is an audiologist and the Director of Stategic Initiatives for the Fuel Medical Group based in Vancouver, Wash, and has served as a managing director and vice president for two of largest hearing aid dispensing networks in the United States, and has extensive knowledge about nuts-and-bolts practice management. In his earlier years, he also built a successful network of five dispensing offices in the Pacific Northwest as a second-generation hearing care professional.

Dan is one of the first people I often turn to when I have thorny questions about practice management, so I wanted to ask his advice about the current business situation.

HR: First of all, my guess is a lot of practice owners and managers are very concerned about cash flow, how they’ll pay staff and overhead, etc. Where should they start?

Before we get into some of this, I think you’ll find there’s some very clear action items to consider if you just sit down and start planning. I think the number-one piece of advice I’d give to practice owners is to take action now. Understand your business’s requirements and options, come up with a thoughtful realistic plan based on your P&L and solid facts about your business; call your accountant and your bank about the PPP loan and other programs; and make use of all the resources you have. And be a leader.

In times of strife, leaders lead. This is not a time to sit back and see what happens. We know that commerce may not fully re-engage for at least 30-60 days; in all likelihood, April will be gone, and May could very well be done before we even start to see things come back—and then probably only in a limited fashion at first. So, understanding what this means and taking action right away is the biggest job of the small business owner when times get tough.

In truth, I think there’s a whole menu of things that a business owner can do right now to improve the prospects of their business, employees, and the future when the pandemic eases up and eventually ends.

HR: So after catching your breath and gaining some perspective on the situation, how do you formulate a survival plan—especially when you don’t even know how long this crisis will last?

There are two things to realize, and I want to be clear that I didn’t invent either: both come right out of Steven Covey’s book The 7 Habits of Highly Effective People.1 The first one is “Be proactive and control the controllable,” and the second is “Start with the end in mind.”

We have to understand that, as small business managers in this very peculiar time of Covid-19, there are some things you can control, and there are others you obviously cannot. So, what you have to focus on right now are the things you can control.

The very first thing you can control is your attitude. You need to be the “can do” person in your business. It might sound trite, but you really do need a “Let’s get this done” kind of spirit. You need to control your attitude, control your planning, and control the activities your business engages at this moment in time.

HR: Okay. That’s good advice. What things should you do right away?

In the short-term, cash is critical. The formula for survival is “cash-available minus cash-out equals survival.” You need to act fast in understanding your financial situation. Begin immediately communicating with your bank so you are prepared when the bank is ready to administer Coronavirus Aid, Relief, and Economic Security (CARES) Act program like the the Paycheck Protection Program (PPP) loans or the existing Economic Injury Disaster Loan (EIDL) Emergency Advance. Looking at the “cash available“ side of the formula, the number-one positive variable is what the PPP loan might mean for your business. The launch of the program has certainly had some hiccups, but it now looks like the Federal Reserve and Congress are working on more aid for small businesses.

I’ll be frank: I ran five clinics in the ‘80s and ‘90s, and there were plenty of economic ups-and-downs during that time. The one big management mistake I can personally point to was not taking action fast enough. As the business owner-manager, you follow the cash flow, right? You can see it every day. But, in hard times, it’s like you’re trying to be brave and stoic for your staff. You know that they know business is down, but you find yourself saying, “Everything’s fine.” In a crisis, be as transparent as is feasibly possible with your staff. Don’t say everything is fine if it is not. Help them understand the importance of making tough decisions today so the business will be there in the future.

What does that mean? It means developing a plan to make sure you and your employees survive financially, but also that the business survives so at the end everyone has a job to come back to. That requires looking at your expenses month-by-month, such as payroll. Examine that “cash-available” versus “cash-out formula,” and see what variables you can control inside of your business.

HR: So, the CARES Act should reduce the necessity for closing a practice, laying off staff, or reducing hours?

Yes, the whole point of the program is to keep people employed, paychecks flowing, and the economy running. Now, short term, it’s altogether possible that many practices have already furloughed or reduced staff hours in order to stay in business—because they’ve been forced to for cash-flow reasons. I’ve received a lot of questions from managers who have moved employees from 40 hours to 30 or 20 hours, with them inquiring what this might mean for the loan repayment. There are specific guidelines in program. Make sure you understand the ramifications of furloughing and reducing hours relative to the payback criteria. Additionally, there are other factors outside of the CARES Act you need to consider, like how much you will have to pay if you let staff go relative to vacation pay, the Expanded FMLA, etc. There are serious considerations in letting people go or laying them off—both for your long-term growth and short-term survival—so you need to be very, very careful and understand what the repercussions are.

HR: What else can you do if your practice is struggling—besides don’t panic!

Well…yes, I don’t think you should panic. But you do need to be proactive. Some practices are seeing patients, while others are only seeing them remotely. However, almost all practices have a lot of downtime. As a practice manager, you should be thinking about revenue generation—even if it’s relatively small—and preparing for your future.

Can you reach out to patients and generate some cash? There are a wide range of activities that can generate cash along the way. Granted, in many cases, it’s going to be small amounts, but most of these activities prepare the way for your business to retain patients, identify potential opportunities, and to rebound more quickly when times get better. Some examples include:

Batteries: Your patients are going to need batteries for their hearing aids, and they certainly don’t want to go out and buy them now. So reach out to them with a phone call to see 1) How they’re doing, and 2) If you can send some to them? Of course, you need to employ safety measures with the packaging, as well as a safe delivery or pickup method by mail or curbside. Your staff can contact every patient who doesn’t have a rechargeable product and see what their needs are: “Let us help you. Here’s a special we’ve got going during this crisis. Let me send you out some batteries.” Granted, it’s not a lot of money, but providing patients with batteries or enrolling them in a battery club involves some revenue generation, shows your concern for your patients, and gives staff members a perfect opportunity to interact with patients—and update files, email addresses, etc, and add them to a list of patients who need to be seen in the office when business is back to normal

Warranties. Similar to batteries, you could also contact people whose products are out of warranty. During times of uncertainty, people want certainty. By offering an extended warranty, you can ensure patients aren’t going to get stuck with a large repair bill in the coming months. Additionally, some practices might consider running a promotion where, if you purchase a new product within a fixed period of time, you can apply the value of the warranty against that purchase. Get on the phone now and talk to your patients about extending their product or services warranties.

Repairs. Obviously, repairs are something any office can do. A lot of practices are creating safe, effective ways for shuttling hearing aids back and forth using drop-boxes, curb-side service, and even express mail. Please practice the safe transfer of products between the patient, the office, and the manufacturer.

Remote mics, TV systems, captioned phones, and assistive devices. Assistive technology products are traditionally the “poor stepsisters” in hearing care; they’re wonderful in terms of utility but extremely underappreciated and underused. How hard would it be to send out a loop system or TV device if someone has the ability to hook it up? Remote mics are vastly underused in our field but boost SNR by up to 14 dB compared to 4 dB tops for directional hearing aids. Why not promote them? Captioned telephones are free for most people with hearing aids and likewise underutilized. Let your patients know about them as a reminder of your offerings.

Teleaudiology. All of the major hearing aid manufacturers, as well as several OMS, diagnostics, and other companies, now offer some kind of telecare capabilities. Utilize this technology. This is a terrific time to research and implement the available telehealth tools into your practice. While you need to check how your state and licensing requirements are treating the delivery of services remotely, CMS and major insurers have relaxed telecare requirements. Relative to CMS and audiology, there are not any billable codes but there are some commercial insurers that might reimburse. There are good resources online to help you with this. Relative to your private-pay patients, you can have remote patient engagement and then bill them for it with their consent. This may not generate a large amount of cash, but, again, it’s generating some revenue, taking care of your patients, and preparing for more future business.

Demo hearing aids. Think about some of the things you might be able to do with demo hearing aids and talk with your manufacturer reps about them. Demo products might be utilized if patient’s hearing aids break, or perhaps if there is someone with older technology that is no longer adequate to meet the patient’s hearing needs. If they have an old audiogram, they can utilize a demo aid programmed to a first-fit—which should be much better than nothing at all. If the demo product has remote programming capabilities, you can clearly adjust the hearing aid to improve the listener’s hearing ability once they have received the product. Then, as we come out of the crisis, these individuals can be scheduled in the office to have a conversation with you about a new product.

Another target for demo products is patients you have “tested and not sold” in the past few months. Following your state regulations, it would be possible to talk to these patients and send out a product for them to try during their time at home.

HR: So again, you’re looking to the horizon and preparing for new business.

Absolutely, that’s one of your two over-arching goals, besides being proactive and creating a plan, right?

Remember all the things you said you’d do for your business if you just had the time? Well, now’s that time!

Remember all the things you said you’d do for your business if you just had the time? Well, now’s that time! Almost all practices will have some downtime, even if they are seeing patients. So, the real question becomes, “How do I prepare to turn the faucet back on and what are the activities we can do RIGHT NOW to correct those problems—or buttress weak spots—our practice was regularly encountering before the coronavirus hit?” Here’s just a few examples that probably apply to most practices:

Optimize your OMS system. Office management software is almost a “must have” for any practice today, no matter the size. If you don’t have one, you almost certainly need one—and they can be scaled to fit your needs. Regardless of whether you have Sycle, Blueprint, TIMS, HearForms, Counsel Ear, or any other OMS system, it’s very likely you’re not getting 100% out of it, because 1) you need to spend time updating, categorizing, and doing general housekeeping on your patient and business records, and 2) you also need time to explore and learn all the things you can do with the software. Now is the time for you and/or a staff member to use the OMS features and ensure your information is correct, that you can identify those patients with a particular hearing loss, or find customers with older hearing aids, or generate a list of tried-but-not-sold patients, etc, so you’re more efficient and can also market specific products and upgrades in the future.

Assess TPAs. Our entire field has been resisting third-party administrators and the insurance groups. If you’re like a lot of practice owners, you’ve been putting off some hard analysis about what each one is actually offering. Now is a good time to become informed about and talk to every major TPA regularly encountered by your practice. You may not like the idea of getting only a fitting fee, but as we come out of this Covid-19 crisis, you should have a clear sense of what your practice can and cannot afford, which plans won’t benefit you, and which TPAs you should bring onboard. Consumers who buy coverage in these Medicare Advantage plans will start searching for hearing aids soon, and you want them in your office—if it’s the right fit for you. Now is the time to get more informed about these TPAs and programs. So, contact the TruHearings, Amplifons, etc, and look at their reimbursement levels, read their contracts, and understand what it means for your practice.

Procure a hearing aid financing/leasing plan. Additionally, as people come back, make sure you can offer them good hearing aid financing options. I like these programs, and the renewals are often very good. Giving patients the option of regular monthly payments, instead of asking for a $3000-$6000 check can relieve a lot of stress for patients, many of whom are on fixed incomes. Like OMS systems or TPAs, there are some important differences between CareCredit, Allegro, Esco, HelpCard, and others. Choose the one you think will best suit your patients and your business, and then offer and advertise it as a payment option.

Clean, purge, and refurbish your office space. It’s a great time to get everything spiffed up. If you’re reasonably handy (or you want to hire someone), it might be a good time to put a fresh coat of paint on the waiting room, replace the bathroom sink and vanity, etc.

Get ahead on the fine-points of patient care. Maybe you always talk about sending birthday cards, anniversary cards, or handwritten notes to your patients to show them how much you care, but never get the time to do it. Or maybe you haven’t seen or heard from someone for two or three years. Here’s where your OMS can come in handy again, and here’s some time where you can purchase some inexpensive cards, reach out to patients, and/or start slipping birthday cards into patient files so they’re ready when the time comes to mail them.

I’m sure there are a lot more projects, some fun and some not-so-fun, that you and your staff can tackle during the downtime.

HR: We’ve talked about the government PPP and EIDL loans, different income generation ideas, and preparing a practice to take off once things get better. Let’s now get into survival tips for those practices really struggling to keep their heads above water. What other options are there for them?

Prioritizing expenses and negotiating payments. Well, any loan you obtain for business survival doesn’t relieve you from tightening your belt and making sure that the loan, combined with any income you can generate and all your other financial resources, are sufficient to cover this economic downturn, right? The last thing you want to do is to run into trouble because you’re unwilling to make the tough decisions as a business person to reduce your expenses or plan appropriately.


So, again, you really need to look at your P&L and your monthly expenses. If you’re struggling, one thing you can do is categorize your expenses into three buckets. In Bucket #1, you have those bills you simply can’t get away with not paying. You will want to spend the most time on your biggest expense which is most likely payroll. You need to analyze personnel duties relative to activities that can generate cash. Other expenses in this bucket might be electricity and heating bills, phone and online, and other utilities.

In Bucket #2, you place those bills you think you might be able to negotiate or pay down over a reasonable time period. This is going to involve a phone call to your landlord, or lender, or supplier, where you ask, “What can I do to temporarily alter how much I pay?” Then see if you can come up with a dollar figure and interest terms. As long as it’s fair and you’ve been a good renter or business partner, I think you’ll find many people will negotiate and help you out.

Finally, in Bucket #3 are those bills you can either delay payment or cut altogether. This bucket is sometimes unexpectedly painful and causes grumbling from the staff, because it can entail things like water delivery service, or coffee, laundry services, or other perks. It can also be hard cancelling services from local small businesses because you appreciate their situation and don’t want to add to their pain. But, right now, you have to put on your business hat, sharpen your knife, and cut the non-essentials. You can bring them back when times get better.

Once you have completed this cost cutting exercise, go back and immediately do it again. This exercise to control cash is difficult. Make the tough decisions. Like a good surgeon, you want to make this cut once and not have to come back later for additional cuts. Do it a third time if you haven’t gotten to a budget you believe you can adhere to.

Credit cards. Be very careful here. It’s absolutely critical to understand what the cost of that money is. Generally, with credit card companies, it’s a lot. Almost always, you’re going to get a better deal at your bank. But I know these are crazy times. Paying bills with a credit card isn’t a great plan, but it might work if you’re sure you can pay it off soon.

Cutting your own salary or draw. Probably, the next one on the list is cutting your own paycheck and expenses. Obviously, this is money for you and your family—one of the prime reasons you built your business in the first place. So, just like your business expenses, you’ll need to look at your own personal expenses and see what must be paid, what can be negotiated, and what can be cut or put off—going through that Bucket #1-3 drill for your own bills. Again, this comes with its own set of perils, as well. After all, this is your family, and you’re now asking them to make sacrifices.

Industry resources. Also, at the risk of making a blatant plug for Fuel Medical and other business networks, if you belong to one of these organizations, I’d strongly recommend asking them for advice. There are some great people and resources in these organizations with a lot of experience you can benefit from in times like these.

HR: What about borrowing from yourself or others?

Any time you consider something like this, you need to speak frankly with your CPA and tax advisor before doing it.

First, in ordinary times, I’m concerned when small businesses borrow from the owner’s personal finances. Be very, very careful with things like this. Not only are you putting your future and/or retirement at risk, but when you bring money from the outside into your business, you must do it the right way. So, make sure to work with your CPA and understand the correct way to get the cash onto your books as a loan. This is not revenue; it is a balance sheet transaction. I’m not saying you can’t or shouldn’t do it in some circumstances, but make sure you do it the right way.

The same holds true for outside private financing, as well. This type of financing comes with its own name: F-and-F financing, or money borrowed from Friends and Family. It’s not necessarily an uncommon or bad thing, but it needs to be done the right way, where everyone benefits and you’re not breaking any rules or placing yourself or your business in peril. Again, talk with your CPA and business advisors.

HR: To wrap things up, there are quite a few options, and most practices should be fine if they act soon enough and prepare for the future?

Absolutely. I hope there isn’t much attrition in terms of practices closing. With the types of government aid becoming available, there really shouldn’t be.

And here’s the good news: the demand is there. We’re a growing field. Hearing aid dispensing has been accelerating at a very healthy and steady clip, and all the demographic numbers and medical research point towards even steeper growth. We still need a lot more hearing care offices and services to satisfy future demand.

I know that, as a profession and as an industry, we have challenges like TPAs and Medicare, OTC, big box, blended care models of distribution, and there certainly will be more threats or opportunities—depending on how you look at them—down the line. However, consumers and the medical community are just now coming to understand how important hearing is to communication, healthy aging, disease management and value-based medicine, and general healthcare.

It might not always seem that way, but I think audiologists, hearing aid specialists, ENTs, and all the hearing-related professions are in an extremely exciting time. Covid-19 will pass, and if you’re proactive and look to the horizon—starting with the end in mind—we can come out of this even stronger than before.


  1. Covey SR. The 7 Habits of Highly Effective People. New York City, NY: Simon & Schuster;1989.
Karl Strom

About the author: Karl Strom is the editor in chief of The Hearing Review and has been reporting on hearing healthcare issues for over 25 years.

Correspondence can be addressed to HR or Dan Quall, MS, at: [email protected]

Citation for this article: Strom KE. Cash-flow in hard times: Managing a practice through Covid-19 and other disasters. Hearing Review. 2020;27(5):14-16.