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Success in aesthetic medicine takes strategy, resilience, and a little bit of moxie.
Aesthetic Visionaries is where bold entrepreneurs come together to share real, actionable insights on building and growing a thriving aesthetic practice.
You already have the talent, the intelligence, and the clinical expertise. This series is your guide to navigating the challenges of entrepreneurship with confidence and clarity so you can reach—and stay at—the top of your game.
Think of it as your business coach, industry insider, and hype squad all in one. Minus the jargon and bad advice.
Ultimately, we’re here to help you stand out and sculpt a business that’s as polished and bold as your work.
Show ID (00:01):
Welcome to Aesthetic Visionaries, the show where we hear from bold entrepreneurs building and growing a thriving aesthetic practice. Let's get into it.
Nicole Strothman (00:13):
Welcome everybody to our webinar, Surviving a Board Investigation: What Every Aesthetic Practice Owner Needs to Know. I'm Nicole Strothman. I'm the GC over at Moxie. And for those that don't know about Moxie, we help aesthetic injectors and med spa owners grow their practice with less guesswork. Anything from marketing to retention to business operations, Moxie provides the tools and support needed to run a stress-free practice. And with that, I am super pleased to announce Sara at Langea Law. Sara is an Ivy League-trained healthcare attorney with over 18 years of experience. She's assisted over 1500 healthcare businesses in a navigating all this complexity in the legal and regulatory world around med spa compliance, helps with board investigations, et cetera. Sara, welcome. Thanks so much for spending the time here with us today. Would you like to give a couple of moments to speak about Langea Law and what you guys are up to over there?
Sara Shikman (01:17):
Yeah, thanks so much. Happy to be here, Nicole, and nice to see you again. At Langea Law, we do lots of different things related to the legal aspect of med spa and aesthetic practice compliance. So since this webinar is about board investigations, I'll just mention that we represent lots of people when they get a surprise visit from the board and we can represent people from beginning to end and help people protect their license. And we'll also talk about how to protect your license so that the chance of you getting a board investigation is lower.
Nicole Strothman (01:50):
Fantastic. Well, and that probably leads me right into the hot topic. So the dreaded happens, the board comes knocking or there's a notice that gets sent over to the practice, what's next?
Sara Shikman (02:04):
Usually what happens is the visit is unannounced. So a lot of times, I would say 70, 80% of the time these days, someone comes in person pretending to be a patient. So the first thing that people need to know is you don't have to engage with this person. As soon as they tell you that they're from the board, you don't need to show them around or open your books or comply with their requests. You can say, hey, we're represented by lawyers. They're going to be in contact with you to schedule the next steps. Just like if you are under investigation for anything else, you wouldn't want to talk to the investigator directly. So here the same way. The next best thing is just to remember, don't panic, call your law firm.
Nicole Strothman (02:46):
And what do you find kind of triggers these investigations to start?
Sara Shikman (02:51):
Most of the time it's some kind of compliance issue, like not doing good faith exams. So for example, a registered nurse running a practice and not having a good faith exam process in place or not being set up correctly in the first place or doing everything correctly and being set up perfectly and getting an anonymous complaint from your competitor.
Nicole Strothman (03:14):
And sometimes we see too from former employees that may have some extra discontent for maybe what happened during their employment too, it sounds like. Do you see that as well?
Sara Shikman (03:25):
Yeah, we do definitely. And it's unfortunate that that happens, but it's something that people do, so you have to be set up to protect yourself from that. But a lot of those types of investigations, if you're set up correctly, we can usually get it dismissed pretty easily, even if it was triggered in a bad way where it was your employee or your competitor or your ex-husband or whatever it is, we've had all kinds of situations. They're going to be looking into your setup and into your processes pretty closely.
Nicole Strothman (03:55):
And do you recommend that they hire an attorney right away or is this a process that sometimes is handled by insurance or maybe both?
Sara Shikman (04:05):
We usually recommend that they hire an attorney right away and then if possible seek reimbursement from their insurance. A lot of times it could be settled for not a lot of money, but once you involve your insurance and they see that there is a claim, even if your claim is denied and your insurance tells you, hey, this is not covered, we're not going to protect you, your rates are still going to go up. So usually we recommend first getting an attorney trying to get it settled as best as possible and then contacting your insurance.
Nicole Strothman (04:35):
Yeah, that's great. And it sounds like once the attorney comes in, they really can take over the communication then with the board and really lead any of those conversations or negotiations. So leaving then the practice owner or nurse to be able to continue going on and they're seeing patients, it sounds like.
Sara Shikman (04:58):
Yeah, it's a stressful thing that happens and the investigators know that it's stressful and they try to put extra stress and pressure on it by making it a surprise and asking lots of questions and asking you for things that maybe even go outside the scope of what they're allowed to ask you. So having an attorney represent you takes that stress out from the situation because we'll handle it and you can go back to business as usual. You don't have to close your practice, you don't have to tell everyone that this is happening. It could be confidential, so it doesn't have to be extremely disruptive. It's not the end of the world, but if you're the one that's primarily handling it and you're not sleeping at night and all the stories that we hear from our clients when they call us, I think it's just better to have somebody handle it for you
Nicole Strothman (05:44):
That can feel very overwhelming. Sure, and I think you hit on a really good point. Can the provider continue seeing patients while this investigation is going on? And it seems like unless the investigator or the documentation has said you must cease and they can still going on business as usual.
Sara Shikman (06:05):
Yeah, absolutely. That's a great question. Exactly like you said, unless the documentation says this is a stop order and that only really happens if let's say you have previous violations or this violation is extremely serious, there's an allegation of a patient death or something like that. Other than that, usually they're not putting in a stop order. They're saying that you have X number of days to be in compliance and X number of days to get them documents.
Nicole Strothman (06:31):
Got it. And what type of documentation do you kind of see that the investigators are looking for?
Sara Shikman (06:38):
A lot of the times they're looking for things like your relationship with your medical director and the contracts that govern it. So in the states that prohibit the corporate practice of medicine, it may be your MSA agreement and your medical director agreement. In other states it may just be your medical director agreement and then they're typically looking for copies of your patient charts and evidence that good faith exams are being done.
Nicole Strothman (07:03):
Got it. A lot, it sounds like. So...
Sara Shikman (07:06):
A lot.
Nicole Strothman (07:06):
It must be overwhelming. Yeah. Then how do you suggest that the providers make sure that they're maintaining all of these documents and a good checklist maybe, it sounds like, to look at or have these documents readily accessible?
Sara Shikman (07:22):
Yeah, I think when providers partner with someone like Moxie, you guys take care of a lot of the documentation aspects of making sure they have everything in an organized way. So I think definitely not doing paper charts or trying to do documentation yourself, keeping everything organized and even if someone is your friend or your relative, not making any exceptions ever for documentation. So a lot of times having a signed consent, for example, people would call us and they say, well, it was like my ex-boyfriend's mother and I didn't do my proper procedure because we're friends. And I think the one thing that's important to know is a lot of times when you're dealing with friends and family, there are even heightened expectations from those people as to great outcomes and your treatment of them and their extra sensitivity. So those people are even more likely to have an experience that leads them to reporting you or something like that, unfortunately.
Nicole Strothman (08:21):
Yeah, that's a really great point and probably something that a lot of these providers don't think about, right, because they do feel like maybe there is a level of trust there, and so they don't necessarily have to have all that normal standard paperwork that their normal patient would sign. So that's really a point to make sure that they're really treating everybody the same with the same level of paperwork and signatures and consent forms as well.
Sara Shikman (08:48):
Yeah, definitely. In many states, you can't really treat people just based on standing orders, so you have to have this initial patient evaluation by an NP, PA or MD before an RN can treat patient. And these boards are very aware of this issue, and that's a very specific issue that they're investigating. So a lot of the investigations that we've been involved in New York, Ohio, California, Texas, are all focused on this issue as the number one thing.
Nicole Strothman (09:19):
Got it. It seems like there is a lot around the RN scope of practice and whether that is being followed or exceeded. We get this question a lot at Moxie even is a lot of these RNs are very talented and so they want to be able to service the clients to the best of their capacity, but they do understand that there is another level of provider engagement around that patient experience. How do you help decipher with say the RNs of even your clients or those that come into your practice where they have been practicing for 15, 20 years and they are the best injector in their local area, so they don't feel the need to go and get a higher level GFE performed because they know it. What would you kind of coach them around that piece?
Sara Shikman (10:11):
I would say that there are a lot of people who are great injectors and are practicing extremely safely even without following some of these legal rules. But the legal rules are still there and the boards don't care whether somebody has been doing it for 20 years. We've had clients where literally the person was doing it for 20 years. They are like a top injector, extremely well known, has thousands of hours of training, and one thing that boards do ask for is evidence of training so they will care. It is a bit of a mitigating factor if you could show 'em your 20 years of experience and all your training certificates, so definitely save those, but the board still say, okay, that's great that you had this training, but the law says you're supposed to have a prescription for this product. Let's use Botox as an example, and you didn't have a prescription. You as an RN are not allowed to write a prescription, so you are in trouble. So they see it as a very black and white issue despite someone being a great injector and having lots of experience.
Nicole Strothman (11:17):
Yeah, that's a great point. The scope of practice is still the scope of practice, so that's a very good point. And let's just say that somebody knows that something went wrong, there's an adverse event, they see it almost right away. The patient's just clearly agitated. They have concerns that this will turn into some sort of board complaint. Is there any process that the provider should be following at that outset to try to prevent some sort of investigation?
Sara Shikman (11:49):
Definitely, and I think one thing people can do is show the patient you really care. The number one source of patient complaints is not so much that their outcome was bad, they could have had a terrible outcome, but if they feel like you didn't care about them, they are much more likely to complain. So first, show them you care. Second, I would try to give them a refund of their treatment. Some people come to us and they say, well, if I give them a refund, is that an admission of guilt? No, it's not an admission of guilt. It's more of showing a gesture that you understand their point and here's a refund. At the same time, you could have 'em sign a release agreement when you give 'em a refund saying that they release you from any claims. Some patients may not sign it, but it's better to at least give 'em the option.
(12:33):
Maybe some will, a lot will. Another option is maybe you could write then and there say, look, I'm sorry that this happened to you. I would love to offer you five free facials or something else. And again, you would offer that to them and then have 'em sign a release agreement. The one thing to know about those is that a patient can't release their right to complain to a board about you. So even if they sign this agreement, technically they can still complain to a regulatory board. They can't ask you for money, but at the end of the day, what we found is when a patient complains, it's because they felt mistreated and they didn't get the financial outcome that they wanted. So a lot of times you could prevent it by essentially giving them a small settlement or giving them some free services.
Nicole Strothman (13:21):
Yeah, that's a great point. I mean, I think patients nowadays, I mean they understand that there is some level of risk to these treatments. They're not new for the most part, treatments that have not been out on the market for a while. And I think a lot of patients do understand that there is a level of complication that could happen. I mean, they see that in the informed consent. So it does sound like expectation setting is important at the outset, but also that bedside manner if something does happen. And that's what I also saw in my past life. A lot of the customer grievances were really around that, how they didn't feel heard, when to your point, didn't have their expectations met in the right way and didn't really feel like they got a resolution that matched what those expectations were.
Sara Shikman (14:10):
Absolutely.
Nicole Strothman (14:12):
If a provider does do something wrong and they're like, oh, geez, this went wrong. Maybe they used the wrong settings on a certain device or created an instantaneous reaction, the patient's not happy no matter what they do, and now the provider's like, oh geez, I'm going to lose my license. Is there anything, I guess short of not receiving the board investigation but really trying to mitigate what happened there? Or I guess maybe going back to if there is then a board investigation and there was something that happened that was incorrect, how do you see these boards are reacting to those types of circumstances?
Sara Shikman (14:54):
So if everything was done correctly, meaning if the practice was legally set up correctly, if the practice followed the correct protocols, if the practice had the patient sign a consent, and the thing that happened was one of the things in the consent, like a burn from a laser and the consent mentioned the possibility of getting burned, then usually even if a complaint is filed with a board, that complaint usually goes away because you followed legally all the standards of care that you were supposed to. But the patient may then also try to get a financial settlement and hire a lawyer, and then you may either negotiate with them through your lawyer or escalate it to your insurance company depending on the amount. So what happens in these cases usually is we could pretty easily get the board investigation piece dismissed, and then the patient, if they're looking for a financial settlement, we would do a negotiation with them and say, this damage was minor, but here's a potential amount of money. Would that work for you and kind of proceed that way?
Nicole Strothman (15:57):
Well, great. It looks like, so we're getting some questions here from the audience, which I'll move over to in a second. Before I do, is there anything else that you think is relevant to chat through before we dive into a couple of these other questions?
Sara Shikman (16:14):
Yeah, I guess one more thing, what I would say is train your staff, like your front desk. If somebody comes and they say that they're from a board, train your front desk staff to say, thank you so much. I appreciate you coming by. Our attorney's information is here. Why don't you schedule a meeting with them so that you don't get into the situation where you were busy with a patient, your front desk person let the board investigator in, and the investigator walked around the whole place and took notes of where your medication is stored, your patient charts and all the things. So my one tip would be to train your staff and also remember yourself. You don't have to welcome the investigator into your practice. You could politely tell them, just contact our attorney.
Nicole Strothman (17:01):
I think that's an excellent point, and a lot of folks in that moment probably feel scared and they're like, oh, geez, I have to let them in. This is somebody from the government. And to your point, letting them know then that they're represented. Any questions, follow-ups, files can be sent from the lawyer over to them. That's a really good point. We've got a question. What's the difference between a complaint and a formal investigation?
Sara Shikman (17:29):
Good question. A complaint is when someone just files something against your practice usually online, and the board member or the representative of the board comes to see if the complaint is warranted. The complaint is just the first step. A lot of times a complaint does not become an investigation if we're able to provide sufficient evidence that you are doing everything right, but if there's any gray area or if it's something very serious, then it proceeds to an investigation, which is a more serious step of the complaint.
Nicole Strothman (18:04):
And how long, Sara, do you see these investigations typically last? How long do some of these folks need to not stay up at night here thinking about this?
Sara Shikman (18:13):
The bad news is that these investigations don't have strict deadlines. So these are government agencies. A lot of times they're understaffed, which actually works to your advantage as well. But at the same time, a complaint and investigation process may last a year. We see it usually range from somewhere between a month to nine months, depending on how extensive things are, but it could be up to a year because what happens is you submit evidence, they review your evidence, they ask for more evidence, you submit more evidence. They may have a hearing about the evidence, like an internal board hearing about it. They may ask you for something else, but the process between each of those may take several weeks and they may be interviews with you, they may be interviews with your staff. So that whole thing takes time. So unfortunately, it's not like a one and done one week kind of turnaround.
Nicole Strothman (19:09):
Got it. Yeah, that sounds like that can be pretty intensive. One of the things I've seen too is documentation. And I've seen examples of where in the chart the provider writes, oh, shoot, used the wrong laser, used the wrong injection type, caused a big mistake. Patient is really just a pain, not a nice person. Says lots of negative things about them all in the chart. How would you kind of recommend some of the charting go that is both protective yet describes what happens during an incident?
Sara Shikman (19:47):
Yeah, I would recommend charting what actually happen in an objective way, like used laser used the following settings, you don't have to write whether they were the right or the wrong settings. You would just chart what settings were used. And then in the chart you would also note anything that the patient complained about after patient said they felt warm or patient felt uncomfortable. I wouldn't put any personal things about the patient where the patient is rude or their personality, because that's not going to really add anything to help you. But I would put the settings without putting any judgment as to what the settings were, whether they were wrong or right. And then in the chart also taking a picture of the patient immediately after, because sometimes patients may say one or two days later, they may talk about, well, I got this and this burn or side effect, but it actually, it didn't quite happen. So always helpful to take a picture right after the treatment just to confirm. Or they say, well, I got this new birthmark or mark on my face from the treatment because you have the picture evidence, you realize, no, they had this all along. So really important, those pictures.
Nicole Strothman (20:55):
Yeah, that's a great point too. Those before and afters are very telling. Well, fantastic. Sara, as always, this has been such a pleasure speaking with you. Anything else to add before we wrap up?
Sara Shikman (21:10):
No, thank you. It's my pleasure. Nice to talk to you.
Nicole Strothman (21:13):
Yeah, thank you so much. And if you're already partnering with Moxie, your PSM team can help answer any additional questions. We've been seeing questions in the chat, and so we'll get back to you on those as well. Thank you so much for joining us today. I appreciate everybody's time.
Show ID (21:32):
Thank you for listening to Aesthetic Visionaries. For more resources on building and growing your med spa, visit joinmoxie.com/learn.