Health care is constantly changing. Stay current by following our blog which covers a variety of current topics and our unique insight. Check back regularly for new posts and subscribe to receive the latest posts directly in your inbox.
Effects of the New Tax Code on Health Care Capital Markets AccessMar 14, 2018
Effective January 1, 2018, the new tax code has both a direct and an indirect impact on health care systems planning to access capital, particularly those which utilize tax-exempt debt.
Health Care in 2018: Tackling Hospital Business Challenges in the Face of Regulatory Unrest and an Evolving Health Insurance MarketplaceFeb 24, 2018
With each passing year, the continued rise in health care costs adds further pressure for change in the delivery of health care services. Change efforts appear to be taking shape on multiple fronts, including regulatory efforts and an evolving public and private health insurance marketplace. On top of these national trends, hospitals will continue to face ongoing business hurdles in 2018, including cybersecurity threats, regulatory requirements such as emergency preparedness, and ongoing challenges with health care provider staffing, reimbursement, and revenue cycle. Hospitals should be prepared as these national and local health care trends are likely to impact all areas of their business, from staffing patient care areas to reimbursement and collections to risk management, and technology.
3 Key Measures to Put Your Health Care Organization on the Path to Successful Succession PlanningFeb 15, 2018
By Tina Nazier
What’s more central to your long-term strength than cultivating good leaders? Healthy organizations grow the next generation of leaders from within and look for leaders who have proven themselves ready to translate strategies into actions and make decisions and judgments that affect both daily and future outcomes.
Succession planning is a deliberate approach to human resource planning to ensure a consistent pipeline of talent for all critical roles within an organization. CEOs—and the board of directors when planning for the CEO’s position—are primarily responsible for succession planning.However, many health care organizations fail to dedicate the resources and energies needed to achieve a deep bench of talented leaders.
Restored Outpatient Acupuncture Services for FQHC and RHC ProvidersFeb 02, 2018
Effective retroactively for dates of service on or after July 1, 2016, outpatient acupuncture services for Federally Qualified Health Center and Rural Health Clinic (FQHC/RHC) providers are restored as acupuncture benefits provided to Medi-Cal recipients.
The following per-visit billing codes are restored (for dates of service through September 30, 2017).
Do Not Use Public ANYTHING for Sensitive InformationJan 26, 2018
By Jeff Olejnik
Many coffee shops, airports, hotels, printing/shipping companies, and libraries have computers and Wi-Fi for public or guest use. Certainly, these can come in handy when your computer battery is dead or you are on a road trip and didn’t bring your laptop or you have a bad cell signal. Whatever the reason, if you find yourself thinking about using a public computer and/or connections, you may want to think again.
Is Your Practice Ready for a Retirement Plan?Jan 23, 2018
There is one crisis affecting the healthcare industry that’s receiving little to no airtime. No, it’s not in the legislative space — and it doesn’t include the words “reform” or “Obamacare.” It’s the poor financial wellbeing of healthcare professionals across the country, a rising issue that could have an irreparable impact on the vast majority’s ability to retire.
If You Aren't Using Data Encryption, You ShouldJan 18, 2018
By Jeff Olejnik
All of the information we send and receive across the Internet is valuable. The data on your computer, tablet, or smartphone is certainly valuable, and you should take steps to protect it. Computers can be configured with full hard drive encryption. Portable devices can usually be encrypted as well as their internal, removable storage devices like SD cards.
Secure Your Mobile DeviceJan 11, 2018
By Jeff Olejnik
Technology advances have allowed mobile devices to work wonders in the palm of your hand. Mobile devices such as smartphones have made it easier to surf the Internet, check emails, VPN into work, and even shop online from almost anywhere. When you add all the stored data on a mobile device with all of its features and abilities, you get an incredibly valuable piece of technology, which is why so many people say they cannot live without them.
How to Create a Strong Password and Protect ItJan 02, 2018
By Jeff Olejnik
Passwords are naturally subject to many different attacks. Shared password conventions can increase the likelihood of passwords being guessed. Shorter passwords of dictionary words with few or predictable numbers (e.g., the year) and not using all types of complexity are easily cracked with freely available tools and inexpensive graphics cards. Using the same password for multiple accounts greatly increases the risk of a breach of many accounts after the breach of one.
President Signs Tax Plan Into LawDec 29, 2017
On December 20, 2017, Congress approved the Tax Cuts and Jobs Act, which provides sweeping changes for tax-exempt organizations. The revised version of the bill carries the title, “An Act to provide for reconciliation pursuant to Titles II and V of the current resolution on the budget for fiscal year 2018.” The bill was signed by President Trump on December 22, 2017.
Following is a summary of some of the key changes. Unless otherwise noted, the changes will be effective for tax years beginning after 2017.
Back Up Your DataDec 13, 2017
By Jeff Olejnik
While it’s impossible to predict when your hardware will fail, it’s safe to assume that it will. What would happen if your phone and computer were caught in a fire? How much work would you lose? The best time to implement a backup strategy is before you need it.
Phishing, Spear Phishing, Whaling… Oh My!Dec 06, 2017
By Jeff Olejnik
Phishing is one of the most commonly used attacks against users. By way of email, those with malicious intent will contact unsuspecting persons, asking them to click a link or download a file. Generally, the end goal is to infect the user’s computer with malware or get them to submit important personal information.“Spear phishing” is a term used to describe a phishing attack that is directed towards a specific individual usually for the purpose of identity theft or other compromise.
Tips For Finding Executive Talent for Rural Healthcare ProvidersNov 29, 2017
The following scenario is one that any rural health care provider dreads but is crucial for the organization to carefully consider as it plans for the future.
The CEO resigns. He has been with the hospital for many years. The governing Board of Directors is taken by surprise at the resignation. The Board was so comfortable with the CEO that it never planned for new leadership. Simply put, there is no succession plan.With the departure of a CEO or other C-suite executive, an organization faces difficult challenges in finding a top-talent replacement.
Is Your FQHC Prepared to Meet the February 2018 UDS Reporting Deadline?Nov 27, 2017
Pain, panic, and angst are what many of our Federally Qualified Health Center (FQHC) clients experience when it comes to the annual Uniform Data System (UDS) reporting that every FQHC must provide to HRSA by mid-February.
If you are an FQHC that does not have a handle on your data and are not incorporating it into your operations on a regular basis, you are probably going to end up with a last minute dash to report UDS and risk discrepancies with your numbers.
Targeted Probe and Educate Is UnderwayNov 27, 2017
By Caryn Adams
The Targeted Probe and Educate review officially rolled out on October 1, 2017. However, some providers received their probes early. This program is across all provider types, and you need to know your risks. Skilled nursing facilities have already received letters for RU rug levels.
The time to prepare is now. This is definitely a situation where you want to be proactive. Any provider could be at risk for any reason. Here are six recommendations to help you prepare.
House Tax Reform Proposal-Tax Cuts and Jobs ActNov 17, 2017
After months of speculation and anticipation, the House has released its version of the comprehensive tax reform bill. The 429-page bill proposes massive changes for tax-exempt organizations. Following is a summary of the key changes. Unless otherwise noted, the changes would be effective for tax years beginning after 2017. The Senate is still working on its own version of a tax reform bill, so the final tax bill that gets passed by Congress and signed by the President could be significantly different from this House bill.
Why Across-the-Board Reduction Efforts Won't Generate Lasting Improvements (and What Will)Oct 26, 2017
By David Kim
We see it often: in their quest to improve performance, health care organizations will take the quick and easy approach of making an across-the-board cost reduction, typically 3-8 percent. Unfortunately, this type of decision making is short-sighted and costs will eventually creep back.
The key reasons that costs creep back are because underlying issues and processes have not changed, and managers have not learned how to manage costs better.
There is a Resource for ThatOct 20, 2017
From cybersecurity matters, to compliance, to overall risk management, health care organizations never have to go it alone. Wipfli’s blogs and articles are intended to provide helpful guidance, but there are also plenty of additional, reliable resources that can serve as starting points for initiatives, as sites for additional insights, or simply as touchpoints for gathering assurances that you’re moving in all the right directions.
Here is a list of the many websites you can confidently turn to for additional information as you continue your cybersecurity and compliance journeys.
Is Your Organization Ready to Respond to an Incident?Sep 27, 2017
When it comes to tornadoes, hurricanes, or other natural disasters, most health care organizations have a practical response plan, one that’s practiced regularly and updated as needed. But when it comes to a cyber-attack, a missing or stolen laptop, or a curious vendor who helps himself to protected health information (PHI) files, does your organization have a swift, practiced, and updated response plan?
Best Training Ideas & Tools for Ensuring SecuritySep 19, 2017
Training employees on privacy and security is a vital responsibility. HIPAA requires that organizations provide training for all employees, new workforce members (i.e., employees, interns, contractors, volunteers, etc.), as well as periodic refresher training.
But identifying your organization’s best practices for achieving security education, training and awareness can be a constant challenge, one that can change with the cyberattack du jour. After all, you can’t expect your employees to know what to do when they encounter the latest threat (e.g., ransomware) if they aren’t being regularly trained.However you choose to design your training strategy, these measures represent a few constant parameters that can help.
Executive Coaching for Health Care ProfessionalsSep 05, 2017
By Tina Nazier
Many physicians and health care executives went into the medical profession to help others improve their health; however, with the demands and pressures placed on them, they are often in need of someone to help them maintain their health. In many cases, health care professionals are overworked, overwhelmed, and overextended, which lead to feelings of ineffectiveness and ultimately burnout. In February of this year, CEOs of top health systems wrote an article in Health Affairs calling physician burnout a public health crisis. For those health care professionals experiencing the effects of burnout, it’s clear they need a prescription for help.
Ransomware and HIPAA ComplianceAug 31, 2017
By Jeff Olejnik
Ransomware attacks continue to escalate worldwide. In fact, an estimated 4,000 ransomware attacks occurred daily in 2016...and that was before WannaCry and Petya!
Healthcare providers and payees are not immune to this type of security incident. Consider the highly publicized incident that took Hollywood Presbyterian Medical Center offline for over a week. Or the most recent ransomware attack on the Women’s Health Care Group of PA that impacted more than 300,000 patients.
Wipfli Merges in HFS Consultants, Creating a Stronger, Nationwide Health Care PracticeAug 24, 2017
Effective August 1, 2016, Wipfli merged a health care consulting firm, HFS Consultants (HFS), into the Wipfli family. Now, on the first year anniversary of the merger, it’s clear that our combining HFS into Wipfli has created a stronger Wipfli health care practice throughout the country and provided a stronger presence in California. We’ve taken Wipfli’s 87-year history and growth into 41 U.S. offices and armed our California team with new offerings, resources, and expertise, making us able to even better help our clients face the challenges of the ever-changing health care industry.
Your Behavioral Health Program Is Losing Money. Here is Why.Aug 18, 2017
It’s no secret that there has never been a robust payment system for mental health care. Mental health services have historically been underfunded and the “stepchild” of the larger hospitals in terms of revenue generation. Payments are inadequate at best, payment models and structures are complicated, and the split between federal, state, and county funding is difficult to understand.
So what can be done? Continue reading today’s blog to learn about five financial suggestions to turnaround your behavioral health program.
You Know You Need to Add a Behavioral Health Program WhenAug 15, 2017
During my experience working closely with numerous behavioral health programs, I have found these three scenarios within hospitals that immediately produce red flags:
- Your emergency department is overrun with psychiatric patients.
- Your providers are begging for help.
- Regulators are beating down your doors with citations and threats.
Ten Steps to Achieve Behavioral Health and Primary Care IntegrationAug 11, 2017
During the past several years, integrating behavioral health and primary care has been touted as a solution to the increasing growing public health problem of untreated mental health and substance abuse disorders.
When primary care physicians encounter patients with mental health issues such as depression, anxiety, or other disorders, the mental and general health needs of the patient can be met by bringing medical and psychosocial services together in the primary care setting. This is a key concept under Whole Person Care and Patient Centered Medical Home models.This blog features 10 steps that you can follow to help integrate behavioral health care with primary care.
The Wide Range of Information/Cybersecurity ResponsibilitiesAug 08, 2017
It’s a tough job, but somebody has to do it.
In many health care organizations, an information security officer position is responsible for facilitating the development, implementation, and oversight of all information/cybersecurity activities. This position goes by many different names: Chief Information Security Officer (CISO), Information Security Officer (ISO), or Chief Security Officer (CSO), to name a few.
Yet they all represent the same thing—the thing that matters to providers both big and small—and that is, it’s important to have a knowledgeable leader in charge of all aspects of security and risk management.
Organizational Information/Cybersecurity: Who's in Charge?Jul 28, 2017
Maintaining information and cybersecurity is a hefty undertaking for health care organizations and an even bigger challenge for smaller health care providers. But what about building a strong, comprehensive organizational information/cybersecurity/risk management program? One that can keep information private, readily available to those who need it, and safe from ongoing threats that continually evolve, are growing in number, and can originate internally or externally from anywhere in the world?
That’s an even greater feat, one that comes with even broader responsibilities that directly impact the business. So, who’s your “organization’s” information/cybersecurity leader? It’s not an optional decision or one to be taken lightly.
Six Ways to Increase Cyber Security in the Health Care IndustryJun 27, 2017
In early June 2017, the U.S. Department of Health and Human Services (HHS) Health Care Industry Cyber security (HCIC) Task Force released the “Report on Improving Cyber Security in the Health Care Industry” (the “Report”). The Report provides six primary recommendations for government and health care organizations to “help increase security across the health care industry.” It describes the health care industry’s cyber security issues as patient safety issues and emphasizes that all health care delivery organizations have a greater responsibility to secure their systems, medical devices, and patient data. The release of the Report is particularly timely in the wake of the ransomware attack in May that crippled hospitals and health systems in the United Kingdom and other businesses and industries across the globe. Cyber security planning is important for all industries, including participants in the health care delivery system—providers, payors, pharmaceutical companies, medical device manufacturers, and vendors.
Strategies to Reduce Physician and Provider BurnoutMay 17, 2017
By Tina Nazier
There’s an epidemic sweeping our hospitals and health care organizations, and it is impacting patients, providers, their families, and medical staff. The problem is physician and provider burnout, and it can adversely affect an organization’s bottom line, and even prove fatal for the provider. Numerous studies, including one reported on Current Psychiatry.com, reveal that the suicide rate for physicians is higher than that of the general population. It’s estimated that between 300 and 400 physicians a year, or one or more doctors a day, kill themselves. While the initiatives covered in this article may not have an immediate and widespread impact on these troubling facts, it is important to raise the issue of provider burnout and highlight initiatives that have proven to help address these concerns.
The Most Sought After Competencies for Executive Talent in Health CareApr 26, 2017
By Ron Some
This is the first in a series of blogs highlighting trends in the market for executive talent.
Despite—or because of—wrenching changes initiated by the executive administration in Washington, DC, the demand for health care executive talent remains healthy due to a couple of trends. As boards of directors and executives contemplate yet more tumultuous change in reimbursement models and via executive orders from CMS and the Department of Health and Human Services, many baby boomer executives, with their retirement savings mostly recovered from the 2008 recession and not wanting to lead another retrenchment effort at their organizations, are scaling back by leaving full-time positions in favor of interim executive work or outright retirement. On another front, as boards of directors become more focused on metrics when evaluating CEOs, they have become increasingly critical of performance and have shown a greater willingness to initiate a change in the executive suite.
"Financial Challenges" Still #1 Issue Facing Hospital CEOsApr 12, 2017
By David Kim
According to a recent survey by the American College of Healthcare Executives, hospital CEOs identified “financial challenges” as their top issue. When the broad category of “financial challenges” is further broken down, 60 percent of CEOs indicated they were challenged with “increasing costs for staff, supplies, etc.,” and 55 percent listed “reducing operating costs” as a concern.
Preparing for the Revenue Recognition Standard - Health Care Part IIIApr 04, 2017
In Part One of the article series, we covered a high level overview of the revenue recognition standard found in Accounting Standards Codification (ASC) Topic 606, implementation issues specific to the health industry, and the high level changes hospitals and clinics will experience from the revenue recognition standard. In Part Two, we covered in more detail, using examples, the five-step process for recognizing revenue, changes to bad debt expense, and the use of portfolios to estimate the transaction price for a group of patients.
What are the next steps hospitals and clinics need to consider as they prepare to implement the revenue recognition standard in the future?
Preparing for the Revenue Recognition Standard - Health Care Part IIMar 15, 2017
In the first article of this series, we covered a high level overview of the revenue recognition standard found in Accounting Standards Codification (ASC) Topic 606. The following is a quick recap of the five-step process to achieve the core principle under the revenue recognition standard:
- Identify the contract(s) with the customer (i.e., patient).
- Identify the separate performance obligations in the contract.
- Determine the transaction price.
- Allocate the transaction price to the separate performance obligations in the contract.
- Recognize revenue when the entity satisfies a performance obligation.
In addition, we discussed implementation issues specific to the health care industry and the high level changes that hospitals and clinics will experience under the revenue recognition standard.
Throughout the remainder of this article, we will illustrate in more detail, through examples, the five-step process for recognizing revenue, accounting for self-pay revenue, changes to bad debt expense, and the use of portfolios to estimate the transaction price for a group of patients.
Preparing for the Revenue Recognition Standard - Health Care Part IMar 08, 2017
In May 2014, the Financial Accounting Standards Board (FASB) completed its revenue recognition project by issuing Accounting Standards Update (ASU) No. 2014-09, Revenue from Contracts with Customers, which can be found in the new Accounting Standards Codification (ASC) Topic 606.
The new standard is effective for periods beginning after December 15, 2017, for public entities which include not-for-profit entities that have issued or are a conduit bond obligor for securities that are traded, listed, or quoted on an exchange or an over-the-counter market. The standard is effective for all other entities effective for periods beginning after December 15, 2018.
Will you be impacted? Continue reading to learn more.
Creating High-Functioning Leadership Teams - Part TwoFeb 22, 2017
By Tina Nazier
Leadership is a critical factor in securing success for today’s health care organizations. Now more than ever before, organizations depend greatly on high-functioning leadership teams. Creating and sustaining those teams demands considerable effort. It requires the implementation and cultivation of five key elements—trust, creative conflict, commitment, accountability, and finally, a focus on results.
Top Eleven Medicare Bad DebtsFeb 08, 2017
The following are some questions to ask your bad debt preparer to ensure that the bad debts being claimed will hold up through a Medicare Administrative Contractor (MAC) audit.
Creating High-Functioning Leadership Teams - Part OneFeb 01, 2017
By Tina Nazier
The race is on for talent in the health care industry. While hiring talented staff and managers certainly impacts success, what health care organizations really need to survive and thrive is healthy teamwork.
Top 10 Pitfalls of Participating in the 340B Drug Pricing ProgramJan 18, 2017
By Vicki LaHue
Given today’s declining reimbursement landscape, most health care organizations are engaging in additional cost-saving strategies. The federal 340B Drug Pricing Program is one such opportunity that is available to critical access hospitals (CAHs), disproportionate share hospitals (DSHs), and other eligible covered entities.
Key Trends Impacting Rural and Community Hospitals in 2017Jan 04, 2017
In our 2016 health care trends article, we anticipated trends that would influence the trajectory of health care and the implications for hospitals and health care providers. Those trends included health insurance, cost containment, the rise of new payment methodologies, technology, analytics, investment, and industry consolidation. These trends certainly gathered momentum throughout the year, and we expect that momentum to continue into 2017 and beyond, with some qualifiers.
Home Health Care Has Had a Busy YearDec 02, 2016
By Caryn Adams
Home health care has had a busy year. There was an increase in audits with Medicare’s focus on retaining its monies, wanting to provide education, and changing the way we assess our clients. Really, it is not as bad as it sounds. We just need to adjust. That being said, change is never easy.
Help Your Senior Living Organization Thrive Financially and OperationallyNov 03, 2016
By Larry Lester
Profit margins for senior living providers who serve Medicaid and low income individuals are razor thin. Without a solid financial plan, an effective budget, and timely response to operational and industry changes, a senior living facility will struggle to survive.
Strategies to Help Your Senior Living Facility Establish a Strong Market PositionOct 06, 2016
As the population over the age of 65 becomes an increasingly larger portion of the U.S. population and health care reform is fully implemented, impacting the senior living industry, competition will heat up to meet the growing demand for senior housing and services and the needs of the local health care systems. Consider it a two front approach to the market. You will need to be attractive to your future customers, and you will need to be just as attractive to your referral sources, the health systems in your area. Such competition and environmental changes can breed innovation by accelerating your facility’s strategies for growth, capital improvements, and systems enhancement and integration.
Using These Strategies for Your Health Care Recruiting?Sep 08, 2016
We all know how hard it is to find good people in today’s marketplace. This is even more apparent in the highly competitive health care industry. How organizations recruit top talent is changing daily as the candidate pool shrinks and qualified candidates become harder to find. Not long ago, running an ad in the local newspaper and posting to the big job boards yielded all the candidates organizations could ever need. This is no longer the case. As the demographics of the candidate pool continue to change and the use of social media increases, it is time to rethink how to recruit in today’s market.
What are You Doing to Create a Positive Workplace Culture?Aug 04, 2016
Staff turnover rates in the senior living industry continue to be increasingly high. Losing employees impacts your facility tremendously by decreasing the quality of care, decreasing resident satisfaction, and increasing recruitment and retention costs.
Can You Answer Yes to Theses 8 Coding Tips?Jul 07, 2016
You are currently experiencing some of the most significant and painful changes to how you collect patient service data with the implementation of ICD-10, the increasing focus on cost and quality, and the dependence on providers to effectively use electronic health records (EHR) all happening at once. You are no longer coding simply for insurance claims payment purposes. Codes are now used for severity adjustment, quality of care assessment, case mix management, public health surveillance, patient safety evaluation, and even marketing efforts. As a result, health care organizations that focus on capturing the most specific and accurately coded data for each patient encounter are collecting powerful information about their patients’ status and condition over time. Certainly, this is important for providing the best care to their patients, but it’s also key to ensuring their practices remain profitable as the Affordable Care Act continues to unwind.
Chronic Care Management (CCM) Services—Not Just Professional ServicesJun 02, 2016
January 1, 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (MPFS) and the Outpatient Prospective Payment System (OPPS) for the AMA’s CPT code 99490 for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions. These services have been overlooked by many hospitals as a “professional-only” service, thus missing a revenue opportunity (hard to find in the world of Medicare payments). Although CMS does not recognize CCM as an RHC or FQHC service, an RHC or FQHC may have the opportunity to bill for CCM on the Medicare Physician Fee Schedule, provided it satisfies the applicable billing requirements for non-RHC/non-FQHC services.
Is Your Senior Living Facility Focusing on These Four Critical Benchmark Categories?May 05, 2016
The sheer size of the baby boomer generation has caused tremendous shifts in cultural paradigms over the last six decades, and boomers’ impact on the practices of our health care system is no exception. Amid a sea of changing health care laws, the needs of the country’s largest demographic are once again making waves across the health care delivery continuum.
Is Your Back Office Working For You or Against You?Apr 07, 2016
By Inga Arendt
There are many tasks required to run a business beyond the provision of day-to-day services to residents. “Back office” tasks do not bring in income and can significantly increase or decrease the costs to run the business. The challenge is to find the most cost- and time-efficient means to accomplish these tasks so that the business runs smoothly and profits are maximized.
Six Key Behaviors to Achieve Value-Based CareMar 04, 2016
By Tina Nazier
By 2016, the Department of Health and Human Services has a goal of having 30 percent of fee-for-service Medicare payments tied to quality or value through alternative payment models such as accountable care organizations (ACOs), value-based reimbursement, or bundled payments. According to the HHS news release on January 26, 2015, this will jump to 50 percent by the end of 2018. Is your organization ready to meet the challenge to achieve value-based care by next year?
Top Ten Questions Regarding Provider-Based ClinicsFeb 04, 2016
By Vicki LaHue
Each month Wipfli’s Revenue Cycle Team contributes insights to the Health Care Perspective newsletter. This month we highlight questions regarding provider-based clinics and the filing of an attestation. Provider-based clinics are under more scrutiny than ever before, so it is important for facilities to ensure their clinics are meeting CMS criteria.
TRUST: The Most Powerful Innovation in Health CareJan 07, 2016
By Tina Nazier
As a health care leader in an ever-changing world, you know the importance of constantly rethinking the way you deliver care. In order for health care organizations to survive, they must consider how to transform traditional health care by harnessing the power of innovation.
Why Construction and Real Estate Entities Need to Care about Revenue Recognition
Live Webinar - 4/24/2018 11:00:00 AM
Rural Health Clinic Conference - Green Bay, WI
In Person Event - 4/24/2018 12:00:00 PM
BSA Workshop Assessing and Managing Risk - Wisconsin Dells, Wisconsin
In Person Event - 4/25/2018 9:00:00 AM