Blind Spots in Dentistry™:  Refusal of Non-Elective (Mandatory) Treatment

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.