Retake Control in 2012
Welcome to the New Year. Like many of you, I appreciate the opportunity for a fresh start that January 1st offers. For practice owners, it’s time to refocus, revisit priorities, and recommit to implementing systems that will enable you to achieve real success in the coming year. Below are my top 10 recommendations for a successful 2012. If you are ready to retake control of your practice, enjoy greater prosperity, and experience considerably less stress, read on.
10. Give and Receive Feedback
9. Recognize and Reward Your Team
8. Stop and Listen to the Person behind the Patient
7. Make the Most of a Treatment Coordinator
6. Establish Specific Job Descriptions for Each Employee
5. Create a Superior New Patient Experience
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To Inlay, to Onlay, or to Crown?
My question concerns billing insurance for inlays and onlays. I call the benefits administrator and find out that inlays are a covered benefit, but when I submit for payment it is often paid at an alternate benefit of an amalgam or sometimes a posterior composite. The patient is always upset when the payment is not what they expected. Is there a way to guarantee a more accurate outcome for this situation? Should we just crown the tooth and get paid?
Betsy, Business Coordinator
The information you receive from the benefits administrator has little to do with the final payment. This information is always qualified with a statement of “this is not a guarantee of payment.” An inlay may be on the list of covered benefits, but it is subject to review from a dental professional paid by the insurance company before the check is drawn. This review may result in a decision to allow for an alternate benefit or a complete rejection.
Each insurance company has a different criterion for consideration of payment for restorations. An amalgam filling is still considered to be a satisfactory and long-lasting restoration, despite the popular and supported opinion that an inlay is less invasive, better fitting and less stressful on the remaining tooth structure. A cast inlay also lasts longer and does not stain or wash out over time. The issue here is what the patient wants. Does the patient want an adequate, less expensive amalgam or composite, or a nice cast restoration? If the answer is an inlay, you can have a three-way conversation with the insurance company administrator to get clarity on how the inlay billing will be handled. You must also have an understanding from the patient that s/he is proceeding with the assumption that s/he will have to pay for the difference between the filling and the inlay.
It is often said that a “good narrative” is the answer to getting paid. Were it that simple, all inlays would be paid. A narrative is necessary for proper documentation of the procedure, but again does not guarantee payment. A pre-authorization will clarify whether the inlay is a benefit of a particular policy, and though there isn’t a guarantee, most of the time the payment will come through when billed.
An inlay is not the same as an onlay and an onlay is not the same as a ¾ crown. An inlay is a restoration that lies within the cusps of the tooth and is fabricated from an impression, to correspond to the form of the prepared cavity area. The restoration is then cemented or light-cured into the tooth creating an excellent bond. An inlay restores portions of a tooth that might also be restored using amalgam or composites.
An onlay is made and placed the same way, but its purpose is to also replace the cusp or cusps of a tooth. An onlay must have the inlay component in addition to the onlay that is replacing a missing or fractured cusp. In the narrative, you must mention the fractured cusp or cusps to be paid for an onlay. Often an x-ray will not sufficiently demonstrate the defect in the tooth requiring an inlay or onlay. An intraoral photo properly labeled with name and date of birth of the patient with arrows pointing to the fractures and defects within the floor of the tooth helps. Some insurance companies do not accept intraoral photos, so a proper narrative is imperative.
The preauthorization request should contain a narrative explaining why an inlay or onlay is the best treatment, as well as an attachment of pertinent documentation such as an x-ray and an intraoral photo. Example:
(1) Existing restoration is an occlusal composite with recurrent decay. Vertical fracture lines are apparent on #12. The patient describes the tooth as painful to chewing. An inlay will strengthen the tooth and not stress the fracture lines.
(2) Existing restoration on tooth #2 is an MOD amalgam with decay undermining cusps on DL and MF. Eighty percent of the cusp incline for these cusps is involved. An onlay will restore the tooth to function by replacing the cusps and strengthening the tooth. The onlay will also facilitate flossing between the teeth as it will be a better fitting, smoother surface.
If the tooth has sufficient decay, fractured cusps, broken or defective restorations, and other fractures involving at least four surfaces, a crown would be the best restoration. Performing and billing crowns that are not warranted because of the higher chance of being paid by the insurance company is fraudulent and unethical. Most importantly, have your patient involved in the decisions regarding their dental work, and they will not feel victimized by you when payment is due.
Practice Building Resolutions
As I drove to work this morning, I noticed more people than normal jogging in the warm morning air. I would suspect that the new additions to the typical morning runners have declared at least one New Year’s resolution - to get more exercise. Have you made 2012 New Year’s resolutions for your practice? If not, here are some suggestions for your January monthly meeting.Conduct Monthly Meetings. Why? Because you understand the importance of your staff working together as a “team.” Teamwork is always high on the list when I ask employees to name a weakness in their practice. So what does this mean exactly?
2. Everyone understands what it takes to reach the daily goal and is made aware at the morning meeting if the producers are scheduled to their daily goal. If not, what can be done to help them reach their goals?
3. Weaknesses or “critical issues” are discussed from a pre-determined list of agenda items. These issues are brought to the table by the Meeting Coordinator (which is rotated each month among the team members), discussed, and resolved when possible. These new tasks are added to the current “Action Plan” list for review at the next monthly meeting to ensure implementation.
4. Monthly statistics for the practice are reviewed. You wonder why your team doesn’t understand why you are not happy with them after you review your P&L, pay bills, etc? They are not privy to the business details of the practice, so how can they be as concerned as you are? I am not saying they need to understand everything about your financial relationship to the practice, as you will see when this is covered in more detail below.
5. Use this time to discuss new clinical techniques that you have implemented or are considering implementing. It is not uncommon for me to hear that the doctor has started recommending a snoring appliance and the business team was never informed! How can they support a treatment plan that includes this product if they don’t even know about it?
6. Help your team to feel like they are a part of your practice and have a voice. If you don’t allow them to speak freely about their concerns for the practice in a safe and controlled environment, they will never speak and you will be rowing your boat alone. That is really hard work!
Conduct Morning Meetings. Why? This meeting brings everyone together in the same room for 10-15 minutes each morning to begin to focus on the patients and the schedule. It ensures that everyone arrives on time and instead of spending the first 15 minutes discussing their weekend activities on your time, it is used productively as a team activity. What happens at the morning meeting?
1. Each hygienist reviews their patients scheduled for the day, using the routing slip to indicate incomplete treatment, past due family members that need to be scheduled, medical alerts, etc.
2. The assistant(s) review the doctor(s) schedule for discrepancies in the treatment that is indicated, any clinical comments by the doctor, treatment not completed, lab cases, etc.
3. The financial coordinator discusses any financial concerns with any of the patients coming in. She also reports on the dollars that are scheduled for each provider for the day, as well as whether the individual goals were met by each provider for the previous day.
4. Everyone reviews the schedule as a whole and discusses any “traffic jams,” openings, or other scheduling concerns that can be corrected.
5. Most importantly, celebrate with a daily bonus program to recognize goals that were reached for the previous day! In many cases, dentists are not good at giving out “attagirls” and “attaboys.” Implementing a daily ping-pong draw bonus, for example, takes the place of the doctors bragging on their team’s hard work and dedication.
Monitor Practice Statistics - Have a Scoreboard! Why? Reviewing your production and collections at the end of the year is too late! Production goals should be reviewed daily and the business performance of the practice should be reviewed and discussed monthly at the monthly meeting.
What should be monitored? For example, how many new hygiene patients treated and who referred them. You should know what your top referral source is so you know where to spend your marketing dollars. How many patients are being inactivated each month as a result of falling out of your 5-step recall follow-up program? If you are inactivating more “active” patients than you have coming into the practice, your practice is not growing.
How much do you adjust off your gross production each month? Why is it being adjusted? Are you collecting 100% of your adjusted production after any bad debt is written off? Are your Accounts Receivables no more than 1x your monthly net production? Are all your insurance claims 60 days and older paid? Are your accounts over 90 days only 10% of your total AR?
These are just a few examples of practice statistics that should be monitored monthly. Goals should be set for these categories based on an annual goal for increased production and collections that take into consideration fee increases, salary increases, etc.
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