Troublemaker on Your Team?
Dr. George Jewson – Case Study #312
Dr. Jewson contacted McKenzie Management seeking help. Contrary to many of the inquiries that we receive, he wasn’t concerned about the number of new patients dropping off, openings in his schedule and other common issues. His production adjustments were out of control, in his opinion, and this was affecting the revenue of his practice.
Dr. Jewson’s practice had a monthly gross production of $83,000 and a monthly net production of $45,650. This was production adjustments of $37,350 or 55% of his gross production. Collections were $44,737 or 98% which appears to be excellent, but the red flag is the large amount of production adjustments.
Why are adjustments used?
Dental software programs are set up with basic adjustment codes, such as Credit and Debit Adjustments, Miscellaneous Adjustments, Refunds, Insurance adjustments, etc. In order to improve the use of production and collection adjustments, I recommended that Dr. Jewson establish more specific adjustment codes.
Production (Credit) Adjustments
Collection (Debit) Adjustments
Production adjustments reduce the dollar amount of the gross production. A practice collects money based on the net production of the practice.
Dr. Jewson was posting over 7% of his gross production to “doctor courtesy.” He was giving away 7% of his production to his friends, other professionals, or patients that he felt guilty charging his normal fee. Every doctor is different when it comes to how much he wants to give away. Dr. Jewson did not realize that he was giving away $5,810 a month!
Bad debt and collection adjustments should be no more than 2% of the gross production. Dr. Jewson’s bad debt and collection adjustments were averaging 3% of the total gross production, or $2,490 a month. Remember that he was collecting 98% and this seemed excellent? Because the Financial Coordinator was writing off 3%, she was writing off $830 more a month than acceptable. This reflects unclear financial arrangements with his patients, as well as a lack of systems for collecting unpaid balances from patients.
PPO adjustments made up 42% of Dr. Jewson’s gross production. This is $34,860 a month. This is a lot of lost revenue due to his participation in PPO plans. Upon further evaluation, it was evident that his Financial Coordinator was posting the insurance adjustments incorrectly. It was not possible to request additional payments from the patients, as this would be very bad for patient relations.
There is no industry standard for PPO adjustments. Some offices have already reduced their gross production for each PPO plan, therefore requiring very little adjustments posted to accounts. Many offices always post their office fees, requiring a much higher PPO adjustment when the insurance check is received. What is important is to confirm that the Financial Coordinator has a total understanding of how to post adjustments correctly and collect the accurate amount from the patient. The remainder of Dr. Jewson’s adjustments were made up of the other codes.
A monthly monitor was created for Dr. Jewson that included all the information listed above. The goal was to reduce the red flag adjustments over a six-month period to allow for increased collections based on a higher net production. A column on the monitor revealed the average over the past 12 months and the anticipated new goal for each adjustment which, in turn, will effect net production and collections. Financial arrangements were established for all the patients that would have an investment that needed to be paid, as well as improved past due collection efforts to reduce the bad debt and collection agency adjustments.
Dr. Jewson stopped giving away his dentistry and realized that his friends and patients still liked him! The Financial Coordinator spoke with various insurance representatives to learn how to properly adjust the patients’ accounts and what the patient is and is not responsible for. At the end of the first six months, the total adjustments were reduced to 32% of gross production, increasing the net production to $56,440. With collections increasing to 99%, the average collections were $55,876. This improves cash flow by $11,139 a month or $133,668 a year!
Contact McKenzie Management to learn how you can increase your revenue without working harder, longer hours.
Who is responsible for charting and documenting clinical records in your office? Ultimately, it is the dentist who must verify that clinical charting is completed and anesthetics, medicaments and procedures are entered correctly on the paper or in the computer. I work with many different practices and observe many systems for recording data, and I am amazed at the diversity of this system. I see the dental assistant writing up the paper chart in one practice and the dentist doing all the charting in the next practice. Two buildings down the street, the dental assistant is entering the treatment plan into the computer charting system as the dentist calls the procedures from the dental chair. When the chart reaches the front desk or the computer screen at the front, the business staff is assuming that all treatment has been entered so that insurance can be billed and co-payments collected.
Complexities arise when there is double entry in the computer and the paper chart, resulting in errors. “I wrote the FMX in the paper chart but I forgot to write it in the computer chart.” Lack of training on the software charting leads the doctor and the staff to keep using the paper chart to enter information and procedures. The clinical note area in the software is often used but the chart is ignored. Treatment planning is often written on the paper chart and then taken to the front office for the business staff to enter while the patient sits in the reception room waiting. The patient has time to think, “the treatment plan must be quite extensive, how am I going to pay for this?”
Dental offices are busy, patients’ needs must be met and it seems that no one is willing to give up a day or even a few hours for software training so that a better and more accurate system can be developed to please the dental team and the patient. This broken system of double entry is full of errors and omissions and should be eliminated as soon as possible. If the computer software has a clinical charting with perio and the x-ray is digital, now is the time to start going chartless. The team should pick a day and from that point on do not create another paper chart. Scan in paper documents, get a signing pad for documents in the computer and start using the software.
Billing insurance companies improperly can result in an investigation and possible litigation. Creating false claims on purpose to defraud is not the same as carelessness in charting teeth surfaces and procedures incorrectly but it can result in the same investigation. For instance, in Doctor Smith’s practice, Sherry billed for a full porcelain crown on #11. The crown was delivered and the claim was paid. The patient never returned to the practice. Two years later, the patient phoned and said that he had just seen a new dentist and was told that he needed a crown on #11 due to the breakdown of an existing filling. The new dentist had billed his insurance for the new crown and was denied for frequency limitations. The patient was accusing Dr. Smith of filing a false claim.
The insurance company and the patient requested the records of Dr. Smith, including the clinical notes. Dr. Smith took a look at the paper chart and the x-rays and concluded that the dental assistant who had charted the day of the prep had written tooth #11 when it was supposed to have been tooth #6. Consequently, the business staff billed the insurance exactly as it was written on the chart, assuming the accuracy of the clinical staff. The statute of limitations has run out to bill correctly for the crown on #6 and the money had to be returned to the insurance company to be applied to the new crown on #11.
The lesson in this story is that posting charting information to the computer software has been proven to be far more accurate. No longer is the issue of handwriting legibility and spelling a concern. It is a much faster system and because of the standardizing it can help eliminate errors. The charting in the software gives a clear visual of what you are charting and you can set up standard wordings to choose instead of having to write each time. The added bonus of the doctor and the clinical assistant charting together makes it easier for the assistant to ask the doctor to check the computer screen for errors before releasing to the front office.
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