Your Financial/Treatment Coordinator has discussed the treatment plan, and the patient has agreed and signed on the option to pay for it. Now you want to track the agreement to ensure it is being adhered to. Your software may have a memo system give you a reminder to check payments are made on time. If the patient is allowed more than 2 payments, and does not opt for a third party payment option, a signed Federal Truth & Lending form is needed.

Statements – 4 steps to improve cash flow:

• Send a statement the day you receive the insurance payment.
• Send statements weekly. Most software systems track the date of the last generated statement and will generate another if one has not been generated within 25 days. This system helps to keep the cash flow more even throughout the month.
• Use auto-customized messages that you create in your software.
• Create a personalized note on the statement, which is generally more effective than a standard auto note. This is also the perfect time to place a call to the patient about their past due balance. You have already audited the patient’s account before placing a personalized note, place the follow-up call too.

Ideally, you want to send as few monthly statements as possible. Have a credit card on file to pay the balance after insurance payment is received. If you must send statements, create a system and use your software’s e-statement option if possible.

You’ve done it, bought your own, previously-established practice. You feel exhilarated, excited, and of course, more than a little nervous. After all, you’ve not only acquired debt, a building and hopefully a bunch of patients, but an existing team as well. Will they like you? Will you like them? What now?

If you find yourself in this position, here is a checklist of things you should do right away:

1. Assemble your own team of advisors – CPA, Dental Consultant, Banker, Lawyer, Dental Sales Rep, for instance. While there may already be a good team in place, you face the risk of being seen by them as an Associate rather than an Owner. It’s important to choose people who understand and agree with your philosophy and vision for your practice, as well as to get independent and unbiased advice.
2. Have a team meeting to review the philosophy of the previous practice and owner, and how your philosophy may be different. Explain your vision and where you want to go. Get feedback from team members – how do they view the practice as it is now? Questions to ask:

• • Do they have the systems and tools in place they need to not only do their job, but enjoy their job?
  • What if anything, would they like to see changed or modified?
  • Do they feel the practice is growing or stagnant, and why?
  • What personal goals do they have for the next year?

3. Review your expectations for each team member and each system in the practice, for instance:

• • What are your expectations when it comes to negotiating payments arrangements?
  • What questions/conversations do you want the clinical team to have with patients?
  • How do you want the hand-off between you and the hygiene department to look and sound?
  • How does the hand-off look like/sound when moving patients from the clinical area to the admin area to handle future appointments, as well as financial and insurance issues?
  • What questions do you want your Assistants to ask prior to onset of treatment, and upon completion of treatment?

If you have been an Associate and are now buying an existing practice, most likely you have some ideas you want to implement that you have not had the authority or approval to act on before now. Ultimately, you must decide early on what you want to see your practice look like and operate, and take steps to put that vision into place immediately.

Part 2 of 3: Blind Spots in Dentistry™ – How to lead and work with an inherited team

For the new doctor who is inheriting an existing team, open and honest dialogue is imperative. Your first priority is to meet with team members individually and encourage them to speak freely and openly about their opinion of the practice as it operated under the previous owner, and what they would like to see happen in the future. This is your opportunity to get to know them better, and find out more about them.

For instance, ask questions like:

• • Do you need help with anything, and if so, what?
  • What tasks are most comfortable for you, and why?
  • What tasks are least comfortable, and why?
  • What is the most frustrating aspect of your job and why? Can you give me examples?
  • What are the biggest distractions you encounter?
  • What aspect of dentistry would you like to learn more about?
  • What can I do to help?
  • What do you need to help you grow your role in my practice?
  • What can your team mates do to better assist you in your role?
  • How do you feel about my vision for this practice?

Allow them time to think about their answers, without rushing them. Think of this process as similar to presenting treatment and payment options. Silence does not necessarily mean ‘no’, it just means they are collecting their thoughts. Be courteous and give them time to consider the question and respond.

Once you have met with all your team members, the following are important next steps to implement:  

Lay the groundwork for handling gossip and communication issues.

Ensure you have a policy manual that has been audited and is current and up-to-date with state and federal laws.

Review job descriptions and make any modifications to adapt them to your expectations. Review the current performance evaluation used. If none exists, create one and implement it.

Establish a schedule for regular team meetings. Stick to this schedule! Leave each meeting with an Action Plan in place – who will do what, by when?

Have measures for accountability purposes to know if your hygiene team is profitable.

Generate reports that will help you understand how the team is working. (This is vital when considering bonuses and raises. It’s hard to know what and how to reward if you don’t know what you are measuring.)

Explain when and why bonuses and raises will be considered.

Discuss the number of patient contacts made and appointments scheduled each month to reactivate reluctant, overdue patients.

Discuss how you will handle cancellations and no-shows, eg:

1. How many of each on a daily basis?
2. How many are filled?
3. Who is taking and making the calls?
4. How are they putting the last-minute or re-scheduled patient into the schedule?

Make a plan for tracking how much treatment was recommended in the previous month versus how much is scheduled.

Remember, your team is as anxious for your new practice to be a success as you are. It’s your job to give them the tools, the rules and the leadership they need to make this happen.

Part 3 of 3: Blind Spots in Dentistry™ – How to transition patients in your newly-purchased dental practice

The practice is now yours, and so are the bills. Now is the time to “start out as you mean to go on.” For instance, have you:

• • Made sure your website and social media reflect your vision and philosophy?
  • Updated or created your “About the Doctor” page? Remember, the first page patients will look at and read on your website is the page about you. Make sure yours is current and well-written. Include appropriate personal information so patients have the opportunity to see you as a person, not just a dentist. Include a good and recent photo.
  • Updated your “About the Team” page, especially if they are new to the practice as well. Include good photos and short bios.
  • Considered holding an Open House, or “Get to Know Us” event?
  • Promoted any new procedures or equipment you are implementing into the practice?
  • Instructed your team to discuss, with enthusiasm, all of the above with the patient, whether on the phone or in person?

And finally, have you:

• • Made sure that you and your team are demonstrating ‘value’ at every patient visit? (This is the part that will help the most with those pesky bills.)

Demonstrating value is vital to the success of any long-term doctor-patient relationship. If a patient leaves your office thinking, “Wow, that’s a lot of money just to look around in my mouth for a few minutes!”, you clearly need to re-think how to better communicate what value you are truly providing that patient.

Here is a common scenario: At Mrs. Smith’s first appointment with Dr. Green, he and his team:

• • Perform an oral exam, including an oral cancer screening.
  • Do a caries risk assessment.
  • Provide a treatment plan, and explain the consequences of delaying or declining that treatment.
  • Provide oral hygiene instructions.
  • Take x-rays or intra-oral pictures.
  • Explained why they need to come back, if sooner or more frequently than normal.

The patient, however, leaves with walkout papers showing only a charge of $$$ for XYZ, let’s say the doctor’s exam.

If the patient does not have a visual record of the procedures that were performed, even though the service may have been included in the cost of XYZ, they have no way of placing a value on that service.

Fast forward a year or so and now Dr. Green is recommending to this same patient that they go ahead with treatment for extensive restorative work. Unfortunately, it is much harder for them to see ‘value’ in his treatment plan because he and his team have not shown them, visit by visit, what they are actually doing to protect their oral health, and why they should trust him now with significantly more expensive treatment. (Intra-oral pictures speak volumes, and should be shown to patients at every visit, especially when restorative work is recommended.)

As a new owner, you and your team need to recognize that your new patients are used to being treated in a certain way, and now the rules are changing. The tendency for a new doctor can be to overwhelm the patient with treatment recommendations before getting to know them. (Maybe the previous owner was lax in certain areas, or maybe Dr. Green’s new diagnostic equipment has uncovered something new.) Either way, it’s imperative for you not to frighten patients away with excessive and enthusiastic treatment planning. Spend time with them. Build relationships. Gain trust. Most patients will proceed with dentistry if they are not hit over the head with it. Make sure your team is on the same page, especially as patients will naturally look to Hygienists and Assistants for verification if they worked for the former doctor.

Consideration must also be given to payment options. Will there be a change in the way you expect patients to pay at the time of service, or will you continue to balance bill them after insurance, a service offered by the former doctor? (As a consultant I do not recommend this. The downside far outweighs any benefit to the practice.)

And finally, will you have the patient sign a consent form, or a declination of consent form, which basically states that they will not hold you liable for their choice not to proceed with treatment?

A well-thought out transition plan is vital if you hope to keep patients you have inherited from a previous owner active and invested in their oral health and in your practice. From their point of view, a change in ownership might be the perfect time to go elsewhere, without worrying about hurt feelings. Don’t let this happen to you. Make sure your patients know who you are, what changes, if any, you plan to make, and finally, how important they, and their oral health, are to your practice.

Do you have patients who are delaying, or completely ignoring, needed treatment? The answer is probably yes, and although you may not always be able to persuade them to accept your dental recommendations, you can try with a letter like this:

Patient Name
Address
City/State/Zip

Dear (Name),

We are writing with an important message about your oral health. A recent review of your chart indicates you have not started or completed dental treatment with Dr. (Name), and we strongly encourage you to contact our office in the next few days to schedule your next appointment.

As you know, if left untreated, dental problems will only get worse, and may ultimately cost more, in both time and money, to treat.
We appreciate that finances may be an issue, and want to reassure you that we will work with you to put in place a mutually fair and agreed financial solution for both you and our practice.

We hope to hear from you soon. Your oral and dental health is very important to us.

Sincerely,

Dr. Name

What does your practice do when a patient refuses treatment, particularly non-elective (mandatory) treatment? Before we begin to discuss this important issue, let’s define elective vs non-elective treatment.

For the sake of this article, treatment in the mandatory category involves infection, pain, discomfort, decay, bleeding gums, fractured teeth, jaw joint dysfunction and potentially life threatening oral lesions. Elective treatment, on the other hand, includes treatment to improve esthetics and function, such as bleaching, porcelain veneers, placement of sealants and other preventive measures, as well as implants, crowns, bridges and dentures. Our main focus is on mandatory treatment, but a system to deal with refusal of elective treatment is important, too. (See more, below.)

So what happens when a patient in your practice refuses mandatory treatment? What do you do? Having a strong system in place to follow up with a situation like this is a blind spot in many dental practices.

Many times, when a patient says ‘No’, they mean “Not today”, but that does not mean ‘never’. If we understand our patients’ wants, what their hot buttons are, and what their current life situation is (ie, other significant expenses like kids in college, graduation, weddings and travel, for instance) the approach we take can assure them we understand what is happening in their life. Our goal is to make sure they understand the benefits of the treatment, as well as working with them on scheduling and financial decision making. If the treatment is elective, keep in mind that research has shown that the buying cycle for elective dentistry is six months.

If, after this, the patient chooses to delay treatment or not move forward, your next step should be to have them sign a “Refusal to Consent to Treatment” letter that explains the treatment prescribed, the benefits to the treatment, and what can happen if treatment is delayed.

In my experience, when the patient is presented with a ‘refusal of treatment’ statement, which details the treatment, the rationale behind the treatment, and an acknowledgement that the patient refused treatment, many patients will change their mind and agree to the treatment. This is a choice. When patients are confronted with having to sign for their choice to not proceed, a typical response is, “Oh, I didn’t know it was that important or urgent.” When this happens, it’s an indication that the clinical team did not fulfill their responsibility of getting the patient “buy in” before handing them over to the financial coordinator — another blind spot in dentistry we will discuss in a future article.

(Note: When they do agree to treatment, do not allow the patient to leave without signing the consent form, signing the financial documentation, and scheduling the treatment.)

Documentation is critical. How many times does a patient say, “I did not know or I was not told I needed that,” even though you have it documented in your clinical notes. This is why you need to have the patient sign a form that they had the treatment explained, what their decision was, and why they refused treatment. Another critical component is the system you have in place to follow up with the patient who refused treatment. Do you have one? Do you use an electronic tickler file? Do you know how much treatment in the month of June you presented to patients, how much was scheduled (ie, what is your success rate?), and the reasons for delayed treatment? A system should be in place to track and follow up with the patient who is delaying treatment.

Without having a system in place to follow up with patients who are delaying treatment, the practice will lose opportunities and the patient will think it is not important or necessary. It is important as well from the business side of the practice to know how much treatment has been diagnosed and presented, as well as how much has been accepted, scheduled and paid for. These numbers are important for the growth of the practice. The numbers can show trends of the business and how well we are doing with our treatment presentation. Where are we falling down? What part of our treatment presentation system needs “tweaking”? They can also protect the doctor and the practice from future liability/ If a patient who has refused treatment goes to another dentist with the same or worsening issue, they cannot claim ignorance as to their situation. (“My previous dentist never told me I had a problem.”)

Elective treatment can be handled differently, as the timing simply might not be right, but having a clear system in place to track the number of treatments presented, diagnosed, accepted, scheduled, reason for delay (if any), and how the team is going to follow up with this is important.

Either way, having a clear system in place to track the number of treatments presented, diagnosed, accepted, scheduled, reason for delay (if any), and office follow up is important, mainly because it protects the doctor and the practice from potential future allegations of misconduct or neglect. For example, the patient who refuses treatment goes to another doctor and claims that he/she did not know they needed treatment for (name of problem or procedure), and that problem has now gotten worse and will require more extensive, and more expensive, treatment to correct.

This should be one of the primary roles for your treatment coordinator, shared with your office’s scheduling coordinator and financial coordinator, depending on your particular setup, one person might assume all these roles. Having a set of guidelines for negotiating payments is a separate topic to be addressed in a later Blind Spots article.

Here is wording that should be included in Refusal of Treatment documents:

Treatment presented by (Name of Doctor) to (Name of Patient), alternate treatment, treatment risks, and risks if treatment is not done.

“Having received a full explanation of the proposed treatment, alternative treatment and risks and risks if no treatment, I have elected to receive NO TREATMENT at this time. By signing below, I acknowledge that I have read this document, understand the information presented, have had all my questions answered satisfactorily and I accept the risks and responsibility for the NO TREATMENT option I have elected.”

The patient and the Treatment Coordinator sign and date the document, which is then stored in the patient’s electronic or paper chart.