Poor Procedures Send Profits Down the Drain
For those of us who routinely grab a latte or double-shot espresso from our favorite corner Starbucks, we probably don't think much about the time a few years ago when this icon of small business success was teetering on the edge of serious financial troubles. It was 2008, the year that is synonymous with financial disaster in virtually every business sector. Stock prices for the ubiquitous coffee giant had plummeted. For the first time, we saw Starbucks coffeehouses actually closing rather than opening one after another and another.
The company's focus turned to the fundamentals of efficiency and careful attention to the bottom line. As is common with businesses that grow too quickly, be they world famous coffeehouses or your dental practice, success can mask a host of system shortfalls and wasted resources. For Starbucks, looking at the fundamentals meant closely examining the basics. For starters, the company was literally pouring tens of millions of dollars down the drain in the form of steamed milk. The baristas would prepare a popular beverage, such as a latte, any milk that didn't make it into the drink went to the drain. With thousands of stores nationwide, there was cause to cry over this case of spilled milk.
Yet as is so often the case, simplicity is the root of all genius. An attachment was added inside the steaming pitchers to indicate how much milk should be used for popular drinks. It would save the company a bundle.
It's the seemingly insignificant details that can turn profit into loss. And it illustrates how major improvements can be made by stepping back and considering the minor matters and everyday procedures that are often overlooked because they have become second nature.
In the dental practice, time and valuable resources are wasted when the dentist struggles to delegate. For example, the doctor may be in the habit of explaining the post-op care to patients, even though that's the assistant's job. Or maybe s/he always sits down with the parents to discuss the importance of sealants for their child, even though this is the hygienist's responsibility. Meanwhile, doctor and staff are stressed because patients are kept waiting too long. It seems as though they are always running behind. And the practice just can't seem to get ahead because capable team members are given only a sliver of the responsibility they can handle. Yet the doctor, who feels as though s/he is spread far too thin, is actually thinking the time might be right to hire an associate.
Rarely do dentists and their teams step back and examine the details of what’s causing stress or concern with particular practice systems, be they delegation of duties, collections, new patients, treatment acceptance, scheduling, etc. Most practices never consider anything but the obvious. “Patients aren’t pursuing recommended treatment because of the economy.” “It seems we are always running behind, so we must need more people on staff.” Certainly, demands on dental practices have increased over the years - and while clinical quality can never be compromised, efficiency in both the clinical and business areas can almost always be enhanced.
How much time is added to a procedure when an assistant doesn’t anticipate what instrument the doctor needs next? How much time does it add to a procedure when the doctor has to repeatedly adjust the light source? How much time does it add to a procedure when the assistant can’t see clearly what is happening in the patient’s mouth? How much does it cost the practice when the assistant or hygienist is not given the responsibilities s/he is legally allowed to carry out? How much does it cost the practice when the doctor is negotiating payment or explaining insurance basics to patients that other staff members could and should be handling? How much time and money is wasted dealing with staff turnover because team members quickly become bored and frustrated that the doctor does not trust them to do more? How much of your “milk money” are you pouring down the drain?
Next week, simple solutions to ensure clinical efficiency.
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The $100,000 Gamble
Ever heard of family obligation discrimination? Unless you've been on the wrong end of a lawsuit in which this was the charge, you probably don't know much about it. But you just might save yourself $100,000 and a whole lot of sleepless nights if you familiarize yourself with the topic, particularly the part about how to avoid being sued for it.
Having spent 18 years suing employers and representing employees who felt they had been wrongfully terminated, that knowledge and experience I now put to work for employers, specifically dentists, who tend to be ill prepared on human resources policies and procedures. In our litigious society, family obligation discrimination is one of the growing areas in which employees are suing their employers. The average verdict in these cases is $100,000 plus attorneys' fees. Dental practices are ideal targets for this type of lawsuit because they hire mostly women with young children and aging parents - the demographic most likely to allege family obligation discrimination.
Making practitioners even more vulnerable for this and other employment related lawsuits is the fact that most offices either don't have human resources policies or procedures, or if they do, those policies have been borrowed from other HR manuals and don't address the specifics of the dental practice.
For those offices that do have HR policies, the approach is typically punitive, and is frequently a trigger for legal action. Employees are often presented with a Final Written Warning. The word “warning” is the term that is so dangerous. I have had hundreds of employees come to me with this document and the word “warning” has caused them to raise their hackles to the point where they go to a lawyer because they feel they have no other options.
Avoid using the term “warning” entirely and use a different strategy such as the decision day discussion and final affirmative agreement. With this approach, the problem employee is brought in and the concerns regarding their employment are reviewed.
They are informed that the time has come in which a change is going to have to be made with their continued employment. However, the employee is told that before the final decision is reached the practice will give them the opportunity to consider if they are committed to the office and the team. To that end, they will have one day off with pay - not for vacation or personal - but for the employee to evaluate their commitment to the practice and consider their options.
When the employee returns, typically one of three things will happen. They will be very concerned about the situation and make the commitment to change their behavior. Or they may quit and never come back. The third possibility is that they come back with a list of grievances.
If they present a list of grievances, it is clear the relationship cannot be mended. At that point, the dentist must listen to the complaints, particularly if there are any references to possible discrimination. For example, “So and so is treated better and she is younger.” The dentist must document the grievances in some form that can be retained. If the grievances are just a rehash of old complaints, the employer can move to terminate immediately. If something new should arise, check it out, but the dentist can still terminate the employee.
If the staff member says they are committed to the practice, present them with the final affirmative agreement. This document acknowledges in writing that the employee will not continue to display these behavior problems for a period of time, typically 180 days. If they do, they will have abandoned their employment and that constitutes a resignation. You've given the employee the opportunity to change and you've created a record proving that the dismissal is non-discriminatory. The employee maintains their dignity and the doctor has the documentation they need to defend any claim that the action was discriminatory.
Remember, the decision day and final affirmative agreement process is something that every practice should use in connection with a comprehensive - but workable - employment practices policy. These should not be used ad hoc.
The key is preparation. Too many doctors believe that if they've never had a claim against them, they never will. That is a particularly dangerous assumption. It just means the chances increase with each year.
Mike Moore is ranked among the best in employment law and has been named one of the top 10 lawyers in Ohio. As Director of McKenzie's HR Solutions, Mike is the creator of the Employment Policy and Handbook, geared to providing dentists who are unsophisticated in the legal arena with a step-by-step policy manual.
Click here to hear Mike present “7 Elements of an Effective Employment Policy.”
To order your “customized” Dental Employee Policy manual Click Here
Building Narratives for Dental Claims
Heed good advice in never claiming to be an insurance expert. The products for consumer purchase in the realm of “dental insurance” are ever changing, so verify eligibility and coverage on each patient. One thing is for certain - to be paid in a timely manner one must give the claims examiner the correct information or you will be resubmitting, or worse, having to go through the time consuming review process.
The most common mistakes seen on claims are the absence of information and attachments. Billing out an anterior tooth as a posterior tooth is careless posting and will result in a denied claim. Giving incorrect information can cause headaches, but not providing enough information can cause the same delay. Below is a formula that may help to get claims paid in a timely fashion. Remember to check the doctor's clinical notes for information on each service and use that verbiage in the narrative. A cookie cutter narrative for every similar claim may end up being a red flag to an examiner.
Multiple 3-4 Surface Composite Restorations
In the case of multiple composite restorations, the evidence of decay and fracture may be required. Replacing amalgam because it is metal or the patient wants white fillings is usually not reason enough to replace restorations. Send periapical with apex and bitewings of teeth treated.
Narrative should include verbiage such as: “Tooth number(s)____ have existing facial or 3-4 surface composite that is cracked, fractured, washed out, leaking or decayed. Remaining tooth structure will not sustain another composite restoration, a veneer is necessary to restore to function.”
Scaling and Root Planing
Include a current FMX and periodontal charting showing comparisons if available. Any other detail from the clinical notes of the dental hygienist or dentist may be added to the narrative.
“Tooth # ___ was extracted because_______________________. Surgical implant placed by _______________to replace missing tooth. Implant crown # ___ and custom abutment # ___ placed to restore chewing function in the arch and to retain integrity of the bone and facial structures”
Keep narratives short, but include the information necessary to give the claim examiner the documentation needed to pay the claim. Supporting information required will vary slightly from one insurance company to another. The above system will help you understand the importance of good clinical notes and excellent radiographs.
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