The Angry Biller
Welcome to the angry biller.
A show where we explore the people and the businesses behind-the-scenes of healthcare, those men and women that are the catalysts that allow providers to concentrate on delivering exceptional patient care.
The Angry Biller
Ep 26 - Transforming Medical Practices Beyond Traditional Boundaries
In this compelling episode, host Josh Fertel is joined by insurance expert Nordia Ramirez from PolicyPro Insurance Agency. With an impressive 25+ years in the healthcare sector, Nordia opens up about her journey and the vital role she plays in helping physicians protect their practices. From her early days in healthcare consulting and marketing to her current role in offering tailored insurance and legal defense solutions, Nordia brings a wealth of experience and knowledge.
The episode dives into:
- Medical Malpractice & Going Bare: Nordia explains the “going bare” concept, where physicians opt out of traditional malpractice insurance, and the risks and rewards of this approach. She shares insights into why certain specialties like plastic surgery and OB/GYN often face higher litigation risks and how prepaid legal defense can be a smart alternative.
- PolicyPro & Legal Defense Plans: Discover how PolicyPro offers solutions for those who prefer legal defense coverage over traditional insurance. Nordia explains the benefits, including flat-rate fees, no waiting periods, and comprehensive representation through seasoned attorneys at Lubell Rosen.
- Practical Consulting Tips for Practices: Nordia shares her unique approach when consulting with healthcare practices, focusing on details that can elevate patient experience—from front-desk etiquette and waiting room ambiance to ensuring billing departments run efficiently.
- Client Success Stories: Listen as Nordia recounts the transformation of a struggling practice, where small but impactful changes helped boost patient satisfaction and overall revenue.
- Essential Advice for Physicians: Nordia emphasizes the importance of having some form of coverage, whether legal defense or insurance, to protect against the financial impact of lawsuits. She passionately advocates for healthcare professionals to educate themselves and take steps to safeguard their hard-earned careers.
This episode is packed with actionable insights and expert advice, perfect for healthcare providers who want to minimize risks, improve their practice operations, and focus on delivering top-notch patient care.
Nordia Ramirez
Experienced Management Consultant, Client Relations, Sales and Marketing professional with a demonstrated history of working in the medical practice industry
Phone: 954-632-5126
Website: https://www.jabribusiness.com
Website: https://www.policyproinsuranceagency.com
LindedIn: https://www.linkedin.com/in/nordia-ramirez-89127711a/
THE ANGRY BILLER, powered by J3 Revenue Cycle Management
Phone: (954) 544-2706
Website: https://www.j3rcm.com/
LinkedIn: https://www.linkedin.com/company/the-angry-biller/
Production of Podcast: VISUALS BY MOMO
Josh Fertel
00:04
Welcome to the Angry Biller, a show where we explore the people and the businesses behind the scenes of healthcare, those men and women that are the catalysts that allow providers to concentrate on delivering exceptional patient care. Welcome to the Angry Biller. My name is Josh Fertel, I'm the owner of J3 Medical Billing and I am your host. We are at the Visuals by Momo studio, very fortunate today. This. Thank you very much. I appreciate you coming on and we could probably sit here and talk for hours about all the things that you know. But let's start from the beginning. How did you get into what you're doing? Tell us what in your background.
Nordia Ramirez
00:57
So I have been working with physicians in the community for over 25 years, from consulting to marketing, to offering legal defense for doctors that have chosen to go bare, and now, more recently, offering medical malpractice coverage for doctors that choose to have insurance.
Josh Fertel
01:15
So what got you into the healthcare? Let's go back 21 years. What got you into healthcare?
Nordia Ramirez
01:19
So my degree is healthcare business administration and I have a minor in marketing. So that's where it all started.
Josh Fertel
01:26
Was there something when you were younger that led you towards healthcare?
Nordia Ramirez
01:30
I like people, I like helping people, I am a people person, right, and I think that helps.
Josh Fertel
01:36
Yeah, no, no, absolutely it does, absolutely it does. And you are like I said, I'm glad that we finally were able to get you to come on.
Nordia Ramirez
01:45
So, policypro, tell us about that PolicyPro is an insurance agency that offers policies for physicians in Florida and 11 other states. Okay, and we work with Bold RRG, which is a new carrier that just came out.
Josh Fertel
02:01
Okay.
Nordia Ramirez
02:07
Fresh on the market able to offer very competitive rates in medical malpractice insurance. So physicians who are in need of insurance and are just exhausted from looking for rates and looking and they can't find rates that are reasonable, we'd be able to help them.
Josh Fertel
02:20
Okay, so let's talk about malpractice a little more in depth, and I know we want to talk about going bare, also in Florida. How does the initial conversation go? You're sitting with a physician. What are you talking about? You're talking about their specialty. You're talking about what they do.
Nordia Ramirez
02:32
So about their specialty and about their needs, okay. So do they want to have insurance or do they prefer to go bare? Let's say that they want to, for In Florida you can. Doctors can go bare.
Josh Fertel
02:44
Okay.
Nordia Ramirez
02:44
So if they choose to go bare, it's usually because they want to minimize their exposure. There are certain specialties that are more at risk, like plastic surgery OBGYNs. These are doctors that are more at risk for being sued and frivolous lawsuits many times.
Josh Fertel
03:00
Yeah.
Nordia Ramirez
03:01
So they just want to take that target off their back and they decide you know what? I'm just want to take that target off their back and they decide. You know what? I'm just going to go bare. But if you go bare you have to have a plan B, because you can still be sued.
Josh Fertel
03:10
Tell us about plan B.
Nordia Ramirez
03:11
So then if you're sued, you have to go and you have to hire an attorney to represent you. That can be very costly, so having a prepaid legal defense plan in place is a way to reduce that risk.
Josh Fertel
03:25
Okay, so tell us, how that works.
Nordia Ramirez
03:27
So the way that works is that you pay a flat fee to a Bell Rosen law firm. I exclusively work with them. They are the best in Florida and those attorneys would represent you if you are sued for medical malpractice or if you're investigated by the Department of Health. Sometimes the case is not taken by a plaintiff attorney and instead the patient decides they want to file a complaint with the Department of Health.
Josh Fertel
03:54
Right.
Nordia Ramirez
03:54
We would also assist you in that.
Josh Fertel
03:57
So it's a one time fee, it's an annual fee, monthly fee, so on average it could be anywhere between 600 and 900 a month.
Nordia Ramirez
04:05
The rate is flat. It stays that way. It doesn't go up every month or anything like that, and if there is a case you're covered from A to Z, even if it goes to trial.
Josh Fertel
04:16
Okay. So first question is that $600 to $900, what percentage of malpractice insurance does that actually work out to?
Nordia Ramirez
04:25
Well, it's not insurance.
Josh Fertel
04:26
But how much are we saving? How much would a doctor be saving?
Nordia Ramirez
04:28
So it depends on the doctor's specialty. So let's say, for example, a plastic surgeon. Say a plastic surgeon was a conservative plastic surgeon that doesn't have too many prior claims Okay, could be paying anywhere between $20,000, $25,000 a year. Okay, so $2,000. We could offer them legal defense for under $10,000 a year Right. Now, the difference is that the legal defense is not going to pay your settlement.
Josh Fertel
04:54
Okay.
Nordia Ramirez
04:54
So you have to be aware of that.
Josh Fertel
04:56
Right gotcha.
Nordia Ramirez
04:57
However, legal defense will pick up your tail, which is retroactive coverage Okay yeah. You can't do that when you have insurance, unless you pay a hefty price.
Josh Fertel
05:06
Right, right, okay. So for the layman, what is TAIL?
Nordia Ramirez
05:10
So TAIL would cover prior acts, meaning that any cases that come up from the past would be covered under the legal defense contract.
Josh Fertel
05:19
Gotcha.
Nordia Ramirez
05:19
So if somebody sued from three years ago before the legal defense was put into place, they would still take care of that or still represent the doctor Correct, and as long as of course, we have to keep it ethical as long as the doctor is not aware that there is already something cooking. And then they sign up for legal defense.
Josh Fertel
05:37
Gotcha.
Nordia Ramirez
05:38
So you have to be honest with us and let us know that you are not aware there's any issue going on and we would cover you completely if a case was to arrive?
Josh Fertel
05:47
Was there a waiting period, so to speak?
Nordia Ramirez
05:49
No waiting period. Nope, no waiting period. You can sign up and be covered on the same day.
Josh Fertel
05:56
Right. So that sounds like a great program. It is. You're saving half of what it would cost you for the malpractice insurance. You're being represented by a big firm that's done this before Very reputable, okay. But now let's talk about malpractice insurance through PolicyPro. So, if you decide that you don't want to go bare You're an old school person and you want that insurance. You don't or you're outside of Florida.
Nordia Ramirez
06:20
What I have found yes, what I have found is that some doctors are affiliated with hospitals that require insurance. Or recently, at the beginning of the year, our Governor DeSantis passed a law that surgery centers that are doing fat transfer are mandated to have medical malpractice insurance.
Josh Fertel
06:39
Surgery centers that are doing fat transfer. Correct, very specific yes.
Nordia Ramirez
06:43
What is known also as BBLs. Those types of procedures. They have to have insurance. It's no longer an option.
Josh Fertel
06:51
Why did they target that specific?
Nordia Ramirez
06:53
I think they've targeted that because it's a high risk procedure and these patients sometimes end up in the hospital Right. So for a number of reasons, but now surgery centers are required to have insurance, and I'm getting a lot of those reasons. But now surgery centers are required to have insurance. And I'm getting a lot of those calls from owners of surgery centers that are looking for coverage because they want to obey the law.
Josh Fertel
07:15
Okay, so tell me why they would come to you as compared to some other person.
Nordia Ramirez
07:20
Because I'm going to give them the best rate.
Josh Fertel
07:22
And how are you going?
Nordia Ramirez
07:23
to do that, going to give them the best rate, and how are you? Going to do that, and not only am I going to give them the best rate because I have such an exclusive relationship with Bold RRG, but also I can guarantee that Lou Bell Rosen is going to be the law firm that's going to represent them.
07:36
So they're not going with an insurance company that's going to outsource some law firm who knows where that they don't know anything about. Maybe it's someone fresh out of school that just doesn't have the knowledge. Our attorneys have over 20 years of experience all of them 20, 30, 40. And this is what they do. This is all they do, so they're going to get the best representation.
Josh Fertel
08:00
That's great. So you have it covered. You have the physician covered from head to tail. Yes, right. So either they're. You have the physician covered from head to tail yes. Right, so we're going to. Either they're going to have the malpractice or they're going to have the defense, and they have this law firm behind them.
Nordia Ramirez
08:13
Yes.
Josh Fertel
08:14
How are you finding your clients?
Nordia Ramirez
08:18
So, like I said, I've been in this community with physicians for so many years that I have a lot of very good relationships. I built a lot of trust with my clients through the years. So my referrals. You know I used to work really hard going out and looking for business and I'd come home with blisters on my toes because you know I was really looking to build my career. And now I just get calls all the time because this colleague gave my number to that colleague, you know. And also Lubell Rosen is very well known. We've already established a reputation for many years in South Florida. So many of the Lubell Rosen clients are already going to feel comfortable getting insurance through this agency because I work with them.
Josh Fertel
09:04
Gotcha. No, that makes a lot of sense. Like I said, they talk about know, like and trust, and you are certainly trusted.
Nordia Ramirez
09:11
Trust is important. It's very important.
Josh Fertel
09:14
So let's skip it, let's go off of insurance for a little bit. You walk into a practice and you know so much about practices. What are the kind of things you look for? The basis of this podcast is to help practices, the people that are behind the scenes, like you, like me. When you go into a practice and somebody says you know, things just don't seem to be looking right, which things just aren't right, we're not making enough money. Whatever it is, what kind of things do you do? What kind of suggestions? What do you look at?
Nordia Ramirez
09:40
So if I go in with my consulting hat, yes, that's exactly right. I'm going to look at it in a very different way and it could be as simple. As you know, the person at the front desk Okay, who they have at the front desk, how they're greeted.
Josh Fertel
09:54
Right.
Nordia Ramirez
09:54
The appearance of the waiting room.
Josh Fertel
09:57
Right.
Nordia Ramirez
09:57
The wait time.
Josh Fertel
09:58
Right.
Nordia Ramirez
09:59
All these things are very important. I always tell my clients you have to be what you want to attract, Okay. So if you want to attract better paying patients, if you want to attract better patients in general, you have to be a better practice.
Josh Fertel
10:13
Right.
Nordia Ramirez
10:14
And sometimes it starts with the most simple things, like the way your waiting room smells, or the way your waiting room looks, or the way that the front desk greets the patient.
Josh Fertel
10:23
Yeah.
Nordia Ramirez
10:24
Small steps.
Josh Fertel
10:26
And what kind of so. Let's move past now the front desk. Now we're in the back, we're in the where everything happens the office manager, the controller, the billing people. What do you look for there when you're doing consulting?
Nordia Ramirez
10:37
Billing is very important.
Josh Fertel
10:39
It's the most important, if you ask me.
Nordia Ramirez
10:40
That's the money. That's the money. You have to have the right billers. Okay, you have to write, and what I've noticed is many practices. They'll take the office manager and have the office manager do the billing. Well, that's not going to work, because the office manager is very busy. They don't have time. She's very busy, she's managing staff, she's doing payroll, she's doing reports, and then, on top of that, you want her to work on denials. You want her to work. It's just not going to be the most productive practice.
Josh Fertel
11:10
Yeah, no for sure. There's only so much time that could be spent, and obviously I'm a little biased. But when you have billers that are salaried employees working from 8.30 to 4.30 with no skin in the game, there's a thought process that goes through that.
Nordia Ramirez
11:29
I always tell my doctors, I tell them you have to motivate them.
Josh Fertel
11:32
Right.
Nordia Ramirez
11:33
Motivate. You know a little bonus here and there. You know all these things are important because it gets very tedious when you're in billing to do the same thing over and over again. But when you're hungry and you want the practice to do well because you're going to do well, then they're going to take off.
Josh Fertel
11:51
Even more reason to outsource.
Nordia Ramirez
11:57
Yes, and outsourcing is excellent because you don't have the person in your office taking up all that heavy weight of all your benefits and all of that and that's all they do. They do your billing, they provide you with a report. You know they're doing a good job because you see the reports quarterly, monthly whatever, and I feel like it's much more beneficial for doctors yeah, and we only get paid when they get paid.
Josh Fertel
12:19
Correct. Give me a great success story that you walked into an office. You said you need to do this, this and this, and poof, something changed.
Nordia Ramirez
12:27
You know I have, I have this one doctor. He knows who he is and the first time we met he wasn't very happy with all the things I had to say because I criticized everything.
Josh Fertel
12:38
It was the ego. Thing.
Nordia Ramirez
12:39
And he wasn't happy. I mean, he went out and bought $200,000 worth of equipment and there was one chair in the waiting room. So I said, if you allow me, I will guide you in the right direction. Right, and of course I signed him up right away for the prepaid legal defense, because he didn't even have that Okay. So I was like you know what, if you're sued? What are you? What are you going to do? You don't have a plan.
Josh Fertel
13:03
Right.
Nordia Ramirez
13:03
So he got that and um, and we slowly started making all these changes to the practice and just changing. Like I said before, you have to be what you want to attract.
Josh Fertel
13:15
Right.
Nordia Ramirez
13:15
You know and you have these expensive machines. We have to attract patients that can afford that service. True true. So we did a makeover. You know. We even changed his lab coat. You know, made many of these changes the appearance of the staff, small things. I wanted all the staff to have the same color uniform and everybody to look professional.
Josh Fertel
13:37
Right.
Nordia Ramirez
13:38
And all these changes. It took a good year, okay Fair, but it came around and it boomed, that's right, you know. So I feel like all these small changes. Right, always end up Make you very successful.
Josh Fertel
13:53
I want to take a little bit of a break, but we'll come back. I want to ask you more about the prepaid legal absolutely are you tired of throwing money at marketing that doesn't work?
13:59
you are not alone, but there's hope. Sign up for leverage digital marketing's free digital marketing audit to see if you're getting the most out of your marketing efforts and budget. Are you ready to stop being angry and start seeing real results? Visit leverageroicom forward slash podcast to claim your free analysis today. That's leverageroicom forward slash podcast. Okay, we are back with Nody Ramirez from PolicyPro. I want to talk a little bit more about the prepaid legal. Just as you gave me a great example of a consultation that you did give me a great success program that we offer at Lou Bell Rosen.
Nordia Ramirez
14:55
A colleague talks to them about it. They receive something in the mail. I happen to meet them and talk to them about it. They sign up and within a couple of months they get sued. I guess that is a great story. I guess that is a great story, because what if you had not signed up for this?
Josh Fertel
15:13
Right right.
Nordia Ramirez
15:14
Then you'd be in a pickle.
Josh Fertel
15:16
Right.
Nordia Ramirez
15:16
Because now you have to go hire an attorney and pay hourly for the representation plus all the fees Absolutely Court fees and everything else Absolutely. So it's a great story because they call me and they say oh, Nordea, thank goodness that we signed up with you, because, look, now we have a notice of intent.
Josh Fertel
15:35
Right. So let's say there's a practice that gets sued. What's the process from there?
Nordia Ramirez
15:42
So when they receive the notice of intent, it's basically that the plaintiff attorney is looking for information. They want to know if you have insurance right they want records on the patient. What you know, there it's, it's the beginning of a lawsuit. So the doctors tend to call me or email me and they're panicking and they're so concerned and they're like but I haven't done anything wrong.
16:07
I don't know why this patient is looking to sue me right and I have to just calm them down and tell them you know we're going to handle everything. Just send me what you have. We're going to have one of the attorneys contact you, ask you questions, and then our attorneys take over. And they're very good, they're very good.
Josh Fertel
16:23
Can I ask how does that conversation then go?
Nordia Ramirez
16:25
So the attorney is going to set up a time to speak to the doctor and just find out what is going to be the easiest way to have our client dismissed from this lawsuit. Many times our client is one of many that are on the lawsuit, so our goal is to have our client dismissed from it.
Josh Fertel
16:44
And stop me if I'm wrong here, but the interaction from the attorney and the doctor, the interaction from the attorney and the doctor once the lawsuit started, that's all paid for.
Nordia Ramirez
16:53
Yes.
Josh Fertel
16:54
So theoretically, no matter how many times they need to communicate or letters need to be written, there's no extra cost. No, extra cost. If, unfortunately, the suit goes the wrong way, all they would really have is the settlement that they have to work on the settlement correct. But other than that it's taken care of Correct, so that's peace of mind.
Nordia Ramirez
17:13
Yes.
Josh Fertel
17:13
And budgeting right, Correct and saving half of what it would cost for malpractice insurance.
Nordia Ramirez
17:21
And it isn't that you're not going to get sued, but you're less likely to get sued when you don't have insurance. No for sure. Well, statistically proven.
Josh Fertel
17:34
It's less of a chance. It's less of a chance of getting sued if you don't have insurance. Correct, right, right, because it's a bigger fight for the plaintiff and they don't know what they're going to get out of it.
Nordia Ramirez
17:41
Correct, they're on contingency. They're taking a big risk.
Josh Fertel
17:44
Yeah, no, I totally get that. That's definitely a yeah, I get what you're saying there.
Nordia Ramirez
17:51
The company, also the PolicyPro, the underwriter that you've been dealing with is so right now, I am exclusively working with Bold RRG, and we have an excellent team of underwriters that have over 30 years of experience.
Josh Fertel
18:07
Where are they located?
Nordia Ramirez
18:08
And they're in Alabama. Okay, georgia.
Josh Fertel
18:11
Right.
Nordia Ramirez
18:12
And we communicate with them all the time. They know our goal. Our goal is to offer our doctors the absolute most competitive rate. Right, we're new kids on the block, right? So we have to be able to bring them the best rate available, correct?
Josh Fertel
18:27
When you are speaking. So now you have really both sides of the fence. When you're speaking with a physician, how do you personally know which way to guide them that's better for them?
Nordia Ramirez
18:36
I know, based on certain questions, that I could ask them. For example, now that we're so busy with the surgery centers that require insurance. These surgery centers have never been insured, so if you've never been insured you can't obtain like a tail contract, meaning like prior coverage.
Josh Fertel
18:54
If you've never been insured, got it.
Nordia Ramirez
18:55
So what I do is I offer them the insurance for going forward, like a first year policy for those claims, and to also be abiding the law, because you have to have the insurance.
Josh Fertel
19:07
Right.
Nordia Ramirez
19:07
But then I offer them a legal defense through Lubell Rosen and that covers them for prior acts. So if that surgery center receives a lawsuit next month from a case that they did six months ago, the law firm would represent them under legal defense, not under the insurance policy. But it's better than Sure. It's better than just buying a first-year policy with absolutely no prior acts coverage and now you're on the hook. So I'm able to offer them both and I don't believe that any other broker can do that.
Josh Fertel
19:42
Right, so let's not a surgical center. My doctor friend I was playing golf. He told me you got to call Nordea because you're just opening up your practice. How do you make that determination as to which way to go?
Nordia Ramirez
19:54
So I'll ask them if they've had insurance in the past. I'm brand new, brand new. You've never had insurance.
Josh Fertel
19:59
Never. I just opened my office for the first time.
Nordia Ramirez
20:01
So you would benefit from having legal defense.
Josh Fertel
20:04
Yes.
Nordia Ramirez
20:05
There's no reason for you to have insurance unless you really want it, unless it gives you peace of mind or it's required of you to have.
Josh Fertel
20:13
Gotcha.
Nordia Ramirez
20:13
Surgery center, employment issues, whatever. If you don't really need it, then you're just starting off. Right, you're low risk, right, you're better off with legal defense, gotcha. But at the end you have to make that decision yourself.
Josh Fertel
20:26
Okay, yeah, I just was wondering if there's a way that you prefer which the legal defense seems to be what you think is the best situation in most cases, not every case.
Nordia Ramirez
20:37
And I'm happy to give them a quote for the insurance. That way they can sit down and think about it. They can talk to their accountant or their spouse or other business partners to make a decision that they're comfortable with.
Josh Fertel
20:49
Are there specific specialties for surgical centers that you target, that you think you do the most help for?
Nordia Ramirez
20:57
High risk. So it will be GYNs and plastic surgeons. Those are the most at risk for lawsuits.
Josh Fertel
21:03
Right, and so those are the ones that you would love to be introduced to.
Nordia Ramirez
21:05
Yes.
Josh Fertel
21:07
If you don't have them all already? Yes, sure, you probably do. No, no. What's the next step for you? Where are you going to go next?
Nordia Ramirez
21:17
I would love to get into other types of insurances. I am a broker so I'm able to sell other types of policies. I know so much more about medical malpractice and I'm so busy with that and I want to be able to provide the best service. But I feel like with time I would like to offer other types of policies for my doctors.
Josh Fertel
21:46
Okay, great, how would?
Nordia Ramirez
21:47
somebody get in touch with you. How is a doctor going to get in touch with you that wasn't referred to you? My cell phone I always pick up. I always pick up when you call me and they can call me at 954-632-5126. Now I'm going to tell you something that everybody tells me that's not sustainable. Right now, if you call me, I can't answer.
Josh Fertel
22:03
Right.
Nordia Ramirez
22:04
But once I finish this interview, I will call you back.
Josh Fertel
22:07
Okay, as long as you call right back, I will. That is not a sustainable model, you know. As big as you back, okay, as long as you call right back, I will.
Nordia Ramirez
22:13
That is not a sustainable model. You know, as you are, as big as you are.
Josh Fertel
22:16
Call me on the weekend, call me at night.
Nordia Ramirez
22:17
I always answer Do you have a website, we have a website, so wwwpolicyproinsuranceagencycom Say that one more time. That's a long one.
Josh Fertel
22:29
Policyproinsuranceagencycom. That's great. That's the website. I got all the information I knew you were going to give me, and you are such an expert in the field. But I have to ask you one more question. If I gave you a magic wand and you can fix anything that has to do with malpractice or legal defense or your business itself, what would you do with it?
Nordia Ramirez
22:47
Goodness, I would just make sure that everybody has some kind of coverage, whether you have legal defense or you have insurance. You need something, and there are so many doctors in South Florida that have nothing and that scares me. It scares me for them. You need to have something. You need to either have legal defense or have insurance, but you have to have something Because a lawsuit is devastating. It can really take a lot. You can lose everything that you've worked so hard for.
Josh Fertel
23:14
Right. Do you think? Just to follow up on it, do you think that the ones that have nothing it's a conscious decision or it's a lack of education? Both yeah. Again, thank you for commenting. I hope you enjoyed yourself. I did Thank you for having me. Next time you have something else you want to talk about, just call me. I hope you enjoyed yourself. I did Thank you for having me. Next time you have something else you want to talk about, just call me. I will. I will answer just like you answer and we will get you back on because I know you're a wealth of knowledge.
Nordia Ramirez
23:38
I will, josh. Thank you, you're welcome.
Josh Fertel
23:40
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