It is Friday afternoon. One of the chairside assistants called in sick this morning, so the remainder of the clinical team works together to pick up the slack. The Dentist is stuck in an operatory surgically removing the root tips of what was expected to be a simple extraction. Your crown prep  that has already been waiting for a while, just  announces to you that they have to leave to pick up a child in an hour.  The handpiece in the hygiene room quit working all of a sudden, so the hygienist had to move her patient to another operatory to polish. There are instruments piling up and lab cases still need to be sent out. Will this day ever end??

The extraction is finally finished, and the hygienist just dismissed her patient.  Just when  the remaining assistants  were starting to see a little light at the end of the tunnel, the Receptionist comes in the back to tell them that there is an emergency patient coming in.  When the assistants ask  her what the patient’s emergency is and she says “I don’t know exactly, they just said that one of their back teeth was killing them”.   The assistants  turn back to their mounting pile of instruments. Their blood pressure goes sky high.  Nevertheless, they take a deep breath and start to gather the necessary items to see this emergency addition to the schedule.  

The patient arrives, and the receptionist  tells the patient that  they haven’t been seen for  over two years , so they need to fill out new paperwork.  The patient was upset about filling out pages of forms and took almost 30 minutes.  Finally, the patient is ready and  the assistant seats them  as soon as they  have an available operatory.  During  triage, the patient  states he has been in pain several  weeks but only  has been swollen for two or three days. He said that since the weekend was coming he thought he should get in.  In reviewing his treatment plan, the assistant discovers that he has been non-compliant with the  root canal treatment he was advised  he needed and missed his last two recare visits.  The Dentist views the x-rays and  re-advises  the patient of  the diagnosis. He prescribes an antibiotic and pain medication and instructs the patient to schedule for the root canal the following week.

The assistant escorts the patient to the front and tells the Receptionist that the patient needs to schedule for the endo. When the receptionist asks what was done, the assistant says the “doctor didn’t do anything today”. 

The Receptionist attempts to collect the patient’s co pay for an office visit and the patient argues that they shouldn’t have to pay because the “doctor didn’t do anything”. Now, the receptionist is stuck dealing with a sticky situation.   Does this sound familiar? We have all had those days.  

 “The Doctor Didn’t Do Anything”… I cringe every time I hear a team member say that!!  To begin with, this patient was an emergency call late in the day and was worked into an already busy schedule. Therefore, there was a disruption of the Dentist’s time reserved for treatment on regularly scheduled patients.  There was a disruption of the assistant’s time because she had to review the patient’s health history, perform triage, take the necessary films, and set up the room for whatever treatment she anticipated the dentist will advise.  Once diagnosed, she will need  to  provide additional  explanation  for  needed procedures, obtain informed consent if necessary, give post-op instructions, dismiss the patient and quickly clean and disinfect the operatory and get set up for their next scheduled patient. There was a disruption of the financial administrator’s time to stop and give an estimate for the next visit and discuss financial arrangements. So, YES… The entire team “did something”.

This situation could run much smoother by just changing a few things.  First and foremost there must be a clear procedure for handling emergency calls.   Many times the front office team members have little or no clinical experience, so they lack the knowledge needed to properly triage the patient when they call. Having an emergency triage sheet ready by the phone, not only prompts the front office on the questions that need to be asked, that same sheet can follow the patient to the operatory so the assistant and the dentist have a basic idea of what the problem is before the patient is seen.

Rather than tell the patient to “come right over”, the receptionist should complete the triage sheet, pull the patient’s chart to see if there is any undone treatment in the area they are complaining about.  In this case, the patient was advised they needed an endo but has not returned for treatment. The patient also said this pain has been going on for quite some time (not usually a true emergency.)  

The receptionist is armed with this info and speaks to the assistant or the dentist. The dentist determines that since the diagnosis had already been made,  it would  be appropriate to call in an antibiotic and pain medication to get the patient through the weekend. This would reduce the swelling and pain, and the patient can schedule for  the appropriate exam  and update diagnostics  to confirm that the  tooth is still restorable. All necessary forms that the patient needs to fill out can be emailed  or faxed to them to complete at their leisure  and bring with them to the appointment.  

In the event that a patient does have a true emergency , it is best to avoid using an office visit or limited exam code. Many insurance companies will consider these as a periodic exam then deny recare exams for frequency. By using D9110 Emergency Palliative code, you are providing a better benefit for your patient. The fee is usually higher, to compensate for the disruption in your schedule, so the dentist benefits as well. Just be sure to document thoroughly.  X-rays are billed separately.

Always advise the patient on the telephone that  the dentist  is “working you in for an emergency visit, and your estimated portion will be $________ when you arrive” .  Also, ask them to come at least 15 minutes early to update and to remind them to bring their current insurance information. I suggest that you collect co-pays when the patient arrives.  This plants the seed that this is a serious situation with financial obligations. Perhaps this will help the patient to value the dentist’s time and treatment recommendations in the future. 

Proper team training will go a long way in avoiding unnecessary emergency visits and will make your day run smoother.

A well trained insurance administrator and treatment coordinator are very valuable members of the dental team. They can usually assist the Dr. with increasing monthly production by several hundred to several thousand dollars. Just think of what that would do for your practice!

Only the Dr. can diagnose and treatment plan. However, once the treatment plan is complete, the Insurance Administrator can add valuable insight in respect to sequencing and timing of specific treatments. The key is open communication between Dr. and team. What I am saying, is, that by making a few little adjustments and using the correct code, you can get legitimate reimbursement for the procedures   that  you already perform.

Patients are always looking to stretch their dollars.  It is important that the patient has an experience that exceeds their expectations and has a greater perceived value of your services than they would have at another office. Dentists have no control over most of their overhead. However, they do have control over their perceived value.

Clear communication with the patient is essential to the success of the practice. Not only should team members be able to effectively speak to a patient, they must also hear what the patient has to say. Most patients are less concerned with the type of treatment needed, and more concerned about out of pocket expense, time off work, etc.

The team must be able to address the patient’s concerns in calm, understanding manor. There is a difference between listening and hearing. You must learn to listen to what your patient is (or is not) telling you.

Seating a patient on time, having a caring, well trained and knowledgeable team, explaining the patient’s benefits to them , educating the patient on their treatment plan, having simple financial policies , and building relationships, are a few things that patient’s place a high  value on. By exceeding a patient’s expectations you will build a base of desirable patients, you will have fewer missed appointments, better case acceptance and your practice will benefit. Your patients will feel respected and appreciated, and will be happy. They become loyal to your office and will refer their family and friends.

It has been my experience over the last 30 years of working in and with dental offices that the ones that take the time to review the patient’s charts, use route slips properly, and have an informative morning huddle are more successful than those who don’t.  It is not productive to gather around and just read the schedule.

It is easy to have tunnel vision & only deal with what the patient is coming in for that day, but when we do that, we miss some significant items.  The biggest culprit of lost opportunities to provide optimal care is the morning huddle. There are important questions to answer….  Does the patient have undone treatment? Did they see the specialist that you referred them to? When was their last complete exam, perio evaluation and diagnostics?  Did they express an interest in teeth whitening that was never followed up on? Do we have a patient on today’s schedule with special needs that will require the use of a specific operatory or wants only a certain assistant?  Does this patient require antibiotic premed and have they been reminded to take it? Will you run out of instruments if you have back to back procedures?  Does this patient only come in when they have a toothache? Is there a balance we need to collect before the patient is seated? By taking the time to prepare your charts for the next day and discuss the day’s schedule, you will be more productive, better prepared and less stressed. You lose credibility when you appear unorganized.

Nothing is worse than having a patient stand at the counter after treatment is done and says they “didn’t know they had to pay today” or “I don’t have my wallet, can you bill me?” Would they go to the grocery store, a restaurant, hairdresser, etc. without expecting to pay?  Could you image asking your car repair shop if they can bill you?

Patients are less receptive to accepting large treatment plans because of the out of pocket costs. It’s not that they don’t understand or disagree with the presentation; it’s that they are usually budgeting their dollars very carefully. Most patients can’t write a check for $1000.00, but they could probably afford $30.00 per month.

This is where your  Financial Administrator or Office Manager helps the patient find a payment plan that fits their budget. Most offices have a variety of long term payment options available for those patient’s that need to stretch out their financial obligation. These can include obtaining an authorization from the patient to do a monthly auto draw on the date that the patient helps determine, from the account of their choice.

Positive changes like this start off small & must start with the Dr. taking  the lead.  It can take some time to get everyone on the same page, and there are always tough choices, but in the end, you will have a much smoother running office, as well as a more profitable one.

How can we expect a patient to value our services if we do not?  Whether speaking to a patient on the phone or in person, you should never ask a patient if they “just need a cleaning,” or “just need a filling”.    When a patient short notice cancels, or no shows for hygiene, I often hear team members say “that’s ok, it was just your cleaning”. 

I once heard an assistant describe   Velscope screening as “just a light the Dr.  uses to see cancer” WOW…. There are several things that concern me about that phrase.   I think this team might need some training!

By using the word “just” its under-mines the importance of the patient’s dental health and urgency for treatment. If we want patients to value our services, we must not minimalize the perception of the doctor’s expertise, or the procedure time involved. Stressing the importance of the procedure will help reduce no shows or last minute cancellations.

Check out your local “help wanted” listings…. most employers are looking for someone with 1 or more years of “experience” in the position they are looking to fill.  Over the last 35 years of my career in clinical, administrative and academic dentistry, I have discovered that “experience” is over-rated. This is exceptionally true with the admin team.     Let me  explain.                 

 In a practice, once the patient has had their diagnostics & treatment consultation, they will be turned over to the person that handles the insurance and the financial arrangements.

   This is where all of your hard work and credibility can implode without proper training. Coding and billing is the one position that has the most financial impact on your practice, and that impact can be profitable or catastrophic.        

       A well-trained insurance administrator is a very valuable team member. They can usually assist the Dr.  increase monthly production by several hundred to several thousand dollars, but It isn’t good enough to have experience, you must be an expert….  EXPERIENCE IS NOT EXPERTISE        

Have you invested in formal training for your “insurance administrator “?  Who actually trained that person?  Was she trained by the “girl that did the job before”?   Or is she  doing things a certain way because that’s “how I did it in my old office?”

  I have had administrators tell me that “the Dr. doesn’t care, so why should I?”  That way of thinking can put your practice at risk, clinically and legally, in the form of  insurance fraud.

   As dental professionals we should set our personal bar very high, always making sure our number one priority to exceed the standard of care. 

      That being said, the responsibility for proper coding starts with the clinical team. I say that because the documentation from the clinicians MUST be accurate if the insurance administrator is going to be able to code properly.

Here are a few  examples of things I see:

A patient has a 3-unit bridge, but only because the abutments are prepped, that’s what gets documented,  so that’s what gets charged out, so the pontic  revenue is lost.

 Tooth needed extracted and added to existing partial… many times that could have been the tooth that was clasped, so not only do we need a new tooth, we need a new clasp. Lost revenue because clasp not billed out.

BW & 2 pa taken on a hygiene patient… after exam Dr. needs one more pa.  BW get billed out but only 2 pas…   more lost revenue.

  I have had office managers say,” well that’s only 1 pa”.   Yes, but let’s say 1 pa @ $25.00 x 3 times a day x 4 day a week x 4 week a month = $1200.00.    Would the manager feel differently if “only “those PA’s were gone from her check?  They are certainly gone from the Dr.’s!   These things all factor in when the team is asking for raises, or more benefits.

Fraud most often reveals itself in situations  such as:

When   a practice will perform a perio maintenance yet bill out a prophy. They do this because it “helps” the patient to be compliant because they have no co-pay.

A patient may be losing their insurance on the last day of the month, but can’t  get in until the first. Again, in order to “help” the patient,  services are dated prior to the end of the month. After all, it is only  a day or two, right?

Charging out for an acrylic partial when  a stayplate was fabricated.

Billing a full gold crown  when a  noble crown was delivered.

I could go on & on & on, but you get the idea.  When doctors find themselves in trouble, there is no intent to commit fraud  or  supervised neglect.  Nevertheless, the Doctor is responsible.

 If the ENTIRE team is not properly trained in accurate, exact, documentation and coding, it will result in a loss of revenue, & could even be considered insurance fraud.  Insurance fraud is definitely not a road you want to take. Fraud can lead to fines, disciplinary action, license probation or revocation, and possible incarceration.  Insurance fraud does not have to be intentional to be prosecuted and auxiliaries are not exempt.    

 Let’s look at this example:

#6-11   pre – auth was sent for  Pontic Porcelain  to High Noble &   Abutment High Noble.   The plan re-assigned the codes & approved for   Pontic Porcelain  to Base Metal &  Abut Porcelain  to Base Metal.   

When the pre auth came back, NO ONE noticed that the codes were re-assigned to a lesser benefit OR that even though it was “approved” the patient was well over his max.  No one advised the patient what his financial responsibility would be. 

 Treatment done…No consent form, no financial arrangements. No communication regarding treatment plan change in the chair to an all ceramic bridge. Pre auth was sent for payment, the insurance paid and the patient was billed the balance of several thousand dollars.   Would you want to be the one that answered the phone when the patient called?   The patient filed a grievance with his insurance company and the Dental Board.  The Dr. was held responsible. The insurance company performed an audit and   the Dr. was ordered to re-imburse the insurance company, and the patient would owe $0.  I’m sure the patient loves their free bridge!!

Team training would have avoided this & brought the approximately $11 thousand dollars of revenue to the practice instead of back to the insurance company and patient.  In reality, the loss is much higher. The Dr. had to absorb chairtime, wages, lab fees, & materials, but perhaps the biggest cost was damage to the reputation of the practice. 

Regardless of how much a patient loves a dentist, they will turn in an instant if the financials are not what they expect.  And you better believe that everyone they know on Facebook will hear about it!

  By investing in team training on coding and business systems, you can actually get paid for the procedures performed, reduce stress, and your patients will be happier. 

Over the last 30 years, I have observed that many, many, practices mis-code crown & bridge procedures, so let me share with you some tips I have learned.                    

 First, there are three common classifications of metals for crowns and bridges.

High Noble D2790 has at least 40% gold content. Noble D2792 has at least 25% gold content and Predominantly Base Metal D2791 has less than 25% gold content. Most plan benefits allow for  Noble Metal, but check with each plan for specifics.

 It is important to talk with your lab to clarify what types of metals your lab is using in order to bill properly.    

If your lab is using high noble, you will be paying higher lab fees, therefore you should treatment plan, document, and bill accordingly. Keep in mind that in most circumstances, the patient will have a higher co- pay due to the upgrade in metals, so make sure to factor that into the patient’s estimate.

 If the dentist bills for high noble and the patient is receiving a noble metal crown, or, if you are billing for noble metal and your lab uses base metal, the patient isn’t actually getting what they are billed for.  It can then be considered insurance fraud, even if unintentional, so you need to be very careful in this area.    

 Let’s look at this actual case:

6-11   bridge pre – auth was sent for D6240 Pontic Porc to High Noble & D6750 Abutment High Noble.   The plan   re-assigned the codes & approved for D6241 Pontic Porc to Base Metal & D6751 Abut Porc to Base Metal  

When the pre auth came back, NO ONE noticed that the codes were re-assigned to a lesser benefit OR that even though it was “approved” the patient was well over his max.  NO ONE advised the patient what his financial responsibility would be.

 Treatment done…NO consent form, NO  financial arrangements.     NO ONE noticed (or spoke up) that the patient and the Dr. changed the treatment plan in the chair to an all ceramic bridge.   The pre auth was dated & sent for payment. The insurance paid the claim and the patient later received a bill from the office for several thousand dollars on top of his estimate that he already paid.

What do you think happened next?   The patient filed a grievance with his insurance company and the dental board for fraud.  The Dr. was held responsible. The insurance company performed an audit and   the Dr. was ordered to re-imburse the insurance company and the patient. That patient got a high end, all ceramic, beautiful 6 unit bridge for free.  

 That was a pretty pricy error.  Let’s take a look at some things that could have been done to avoid this.

1. Have a dedicated person (and a backup person) that is in charge of following up on pre-authorizations. They must read them carefully and understand them completely. They must call or see the patient to thoroughly explain the patient’s benefit, and make financial arrangements.  It is crucial that this conversation take place before the appointment date. This gives the patient a chance to arrange financing, or if they need to reschedule, gives you time to fill that 3 hour gap in the schedule.
2. What role did the chairside play? The consent form must be signed after the patient and the dentist have reviewed the case.  The case should have been discussed in the morning huddle, so if the treatment plan is different from what was done today, that should be apparent and the assistant should have brought it to the immediate attention of the insurance coordinator.
3. Who is entering the treatment? Is there a policy or procedure in place that ensures everything matches and correct codes are put on final claim?

It is crucial that the narratives are complete, conversations are documented, and all treatment verified against the treatment plan.  This will make a smoother and more profitable day, happier patients, and will reduce your risk of audits, grievances, and possible legal action.