Walking Through the Fire
I took a position as an Office Manager in a two doctor general practice six months ago. The previous Office Manager retired after being here twelve years. My problem is that I inherited a huge (over $300,000) accounts receivable (they produce $90,000 a month) plus a large credit balance sheet. I showed it to the doctors and they asked me to “clean it up.”
I started a collection system of three letters and calls to follow-up. The patients that I call say things like this: “Well no one ever asked for money before, how do I know you are correct?” Or, “I sure miss Tessa. She was so nice. She let me pay whenever I wanted.” And even this one, “How dare you send me a “dunning letter. I have been coming there for years. I want to speak to the doctor!” One patient did call to complain and said that the only reason she comes to our office is that we allow her to pay $25.00 a month on her long standing balance. What is the best way to handle this without losing patients and causing stress?
Dear Juanita Rose,
With change comes resistance and distrust. In changing the status quo, you have breached a standard that some patients relied upon in order to have their dental care. This is a fact, not a criticism. You are right in wanting to set up a collection policy and get the accounts receivable to a healthy level. Delivery of this new system to existing patients is challenging. Complaints about your services should be used to enlighten not alarm. Taking the extra time to work out a solution is in order. A standard policy for all patients is the goal. I would recommend the following system be put into place:
When looking at the credit balance sheet do not assume that these figures are correct. Many offices return this money to patients without checking the allowable contract fee and adjust to it. If your doctors are signed up as PPO (Preferred Provider) providers, on some plans, there will be “adjustments” made to contract fees when you receive payment. Even leaving these credit balances on account for patients to use next time can hurt the practice collection if the credit balance is not a “true credit balance.” You will have to compare these balances to the EOB (Explanation of Benefits) to see if they are accurate. Make sure that you have the most current fee schedules on file for all PPOs for which you are signed up as providers. (This year I received several updated fee schedules from major plans.) This will insure more accurate treatment plans and fewer adjustments to accounts. Bill all claims out at UCR. Always tell the patient that the insurance payment is “estimated based on the information provided by the insurance company.”
When sending out statements, a “balance forward” statement is guaranteed to get you a phone call from the patient. They do not know what the balance represents. Send a detailed statement. If you have never met the patient, then include a hand written note on your business stationery and send your own card offering to explain and help them understand the statement.
Most important, you must have support from the doctors. If the system is to work, the doctors must never get involved with fees or payment arrangements.
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Jean Gallienne RDH BS
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In hygiene school, the instructors concentrated on teaching instrumentation, head and neck anatomy, physiology, pharmacology, dental materials, and many other subjects. However, since we as hygienists are not allowed to diagnose, many schools do not spend a lot of time teaching the hygienist about what restorative needs that may be needed. Many of us were taught to mention to the patient if we see a “suspicious area” and that is it. However, by doing this, we are limiting the amount of education that we may provide our patients when it comes to their restorative needs.
Many new graduates from hygiene school have been taught not to diagnose. As a result, the new hygienist is not even talking to the patient when it comes to what they may need to have done. The more experienced hygienist may be aware of potential restorative needs of the patient but she/he does not mention specifics for fear of it being considered diagnosing or being wrong. However, when possible, treatment that is presented in a manner that is not diagnosing, is beneficial to the patient, doctor, and hygienist.
This resorts back to educating the patient about their needs before the doctor ever enters the treatment room. We talked about this in the last article and referred to this process as:
Pre-selling or selling dentistry
Informing the patient about their mouth
Educating the patient
Pointing out opportunities
Planting a seed
Making a suggestion
The hygienist may want to mention to the patient, “Mr. Jones you have a very large old filling in the upper right section of your mouth that we refer to as, #3. It looks stable to me at this time, however, when it does need to be replaced, doctor will probably want to place a crown on that tooth. I will have doctor take a look at it.”
Another scenario would be, “Mr. Jones, it looks like you may have a cavity around the large filling on tooth #3, if it is a cavity, the doctor will probably want to do a crown on it. Let me go get the doctor so he/she can diagnose if anything needs to be done with the tooth at this time. Do you have any questions for me at this time?”
The hygienist should pause long enough so if the patient wants to know what a crown is or why a crown may need to be done instead of a filling, he/she will be able to answer before the doctor ever enters the room. This will help reduce the amount of time the doctor has to spend in the hygiene room. When the doctor enters the room, the hygienist will say in front of the patient, “I noticed that tooth #3 may have a cavity and has a large fill present. I informed Mr. Jones that he may need a crown on this tooth and that you would decide on what needs to be done.” The doctor will now confirm or deny the need for treatment and will do it as not to embarrass the hygienist if he/she feels that a crown is not needed at this time. If treatment is not needed at this time, it is best if the doctor explains why in the hygiene room so the hygienist is able to hear what the doctor says and will be able to look at the large filling again and see what the doctor is seeing and thinking.
Some doctors will move the patient into another room and the hygienist does not have the opportunity to listen to the dentist while the recommended treatment is gone over. Therefore, it is important for the doctor to educate the hygienist on the way they think when diagnosing treatment.
A very easy way to do this is to write down what is seen and what the doctor may do in a flow chart. For instance, one doctor may recommend cleaning out the decay and doing a sealant when there is incipient decay, while another may do a composite and yet another may recommend a professional fluoride treatment, send the patient home with prescription fluoride, and get an x-ray of that tooth in 6 months. Another example is a tooth with a large filling. Some doctors will do an onlay or inlay while others may do a full gold crown, porcelain ceramic crown, or porcelain fused to metal/porcelain veneer crown depending on what they prefer to do and where the tooth is in the patient’s mouth. It is important that the hygienist in your practice is aware of the way you diagnose treatment. Below is a small example of one doctor’s flow chart.
Interproximal, Incipient, (small), decay the tooth has never had a restoration = Watch or composite filling
Endodontically treated tooth, Molar = Build up, 2nd molar FGC, 1st molar PFM less than ½ of tooth crown remaining put post & core
It is very difficult for even the most experienced hygienist to pre-sell dentistry if he/she is unaware of the diagnosing style of the dentist they work for. It is highly recommended that the dentist and hygienist review over the flow chart once the doctor has created it in order to review questions and verbiage that may come up This will enable the hygienist to educate the patient more about their possible needs and to pre-sell your dentistry with confidence.Forward this article to a friend.