4.6.12 Issue #526 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Cash Flow 101 - Get Paid
By Sally McKenzie, CEO

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Billing - it is a fundamental function of running a business. Ideally, payment is collected at the time that dental services are delivered. However, in some cases, patients with a balance must be sent a bill. So why is it that some practices still struggle with this routine business system? Because it’s the “system” that is often lacking.

Let's review the basics. First, every bill sent should include a specific date on the statement that stipulates when payment is expected. Ten days from the date on the statement is reasonable and encourages the patient to pay promptly rather than set the bill aside until later. Second, every bill sent should include a self-addressed payment envelope and include an area where the patient can write in a credit card number if they prefer. Third, bills should be sent daily, not monthly. In other words, your billing cycle is 28 days. Services rendered May 1 are billed on May 28. Services rendered May 2 are billed on May 29, etc. Of course, in an ideal world - there are no bills. Patient has treatment, patient pays. We all know that is the TOP priority.

In today's marketplace, more dental practices are accepting insurance. This can be beneficial for both the patient and the practice, provided practice staff are prepared to follow through. In practices that are accepting assignment of benefits, we often find that financial coordinators do not collect the patient's portion at the time of service. Instead they file the claim, wait for the insurance company to pay, and then bill the patient for their portion. There are generally 1-3 reasons for this: The staff believes that the office software does not allow for the entry of data on different insurance companies, and/or it does not estimate the insurer's portion of the bill, and/or the staff do not trust the software.

More often than not, the computer can accommodate this information but the function was not set up when the system was implemented and will require a call to the software company. In other cases, the employee simply needs necessary training to learn how to do it. And in some practices, the employee knows how to perform the function but contends s/he is too busy to gather the information and enter it into the system.

For doctors who rely on business staff to bill and collect payment, this can become a significant issue. Practice owners often are oblivious to the problem until something serious happens that draws attention to cash flow problems. Without appropriate checks and balances in the practice, it becomes easy for business staff to just blame the “nasty” insurance companies or “irresponsible” patients. However, if effective systems are in place, practices can help to ensure that payments - insurance and others - are received promptly and efficiently.

One of the easiest steps a practice can take is to include a one page insurance coverage questionnaire in the new patient packet. The form asks the patient to provide necessary insurance information and directs the patient to contact his/her insurance company to determine the services covered and the amount the plan will pay. From there, this information should be entered into the practice computer system. And without exception, patients should be asked for their portion of the fee at the time of service.

Additionally, offices that accept insurance must have a financial coordinator who is trained to send claims electronically. This is extremely important to the practice both in terms of ensuring that the practice receives payment from the insurance company promptly, and in terms of significantly improving efficiency of the filing process.

It is essential that the financial coordinator review delinquent insurance claims weekly. The delinquent claims should be grouped by carrier so that one phone call can be made to check on all claims that are 30 days or more delinquent. Speaking of delinquent payments, patients that have not paid their bill should be notified 30 days after services were performed. Messages should be polite and courteous and they should be customized for the specific patient. The more personal the message, the more effective the communication will be. For example:

Dear Ms. Wheat, (You can use the patient's first name if you know him/her well and they have been a patient for many years - Dear Jennifer, …)

We wanted to alert you that we did not receive your payment on March 15 as requested. If you are experiencing financial difficulty, please contact Peggy in our office. Otherwise, we would appreciate your prompt attention to this balance by sending payment before April 6.

For more scripting, GO HERE

Before contacting patients, do your homework. Review the account history. Confirm that there is not an insurance issue that might be delaying matters, and make sure the practice is not in error. Never apologize for requesting payment. A dental practice is a business that cannot effectively deliver necessary services to patients without necessary cash flow.

For more information on this topic and for additional Dental Practice Management info, visit my blog: The Lighter Side.

Interested in speaking to Sally about your practice concerns? Email her at sallymck@mckenziemgmt.com.

Interested in having Sally McKenzie Seminars speak to your dental society or study club? Click here.

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Carol Tekavec, RDH
Hygiene Consultant
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Worries Over Bisphosphonates
Carol Tekavec RDH

About five years ago I began to hear about problems women were having with osteonecrosis of the jaw from taking a class of drugs known as bisphosphonates. In some cases the women developed the condition spontaneously. In other cases it resulted subsequent to an extraction or other invasive dental treatment. While this was distressing enough, at the time a predictable course of treatment for this type of osteonecrosis was not agreed upon by medical and/or dental specialists. Now known as BIONJ (bisphosphonate-induced osteonecrosis of the jaws), the condition reveals itself as exposure of bone in a jaw that persists for more than eight weeks.

Bisphosphonates are a category of drug given to persons who are suffering from osteoporosis; a serious condition which is characterized by thinning of bone tissue and loss of bone density over time. Osteoporosis is considered to be the most common type of bone disease. It is estimated that 1 out of 5 women over the age of 50 have osteoporosis, and about half of these women will at some time experience a fracture of the hip, wrist or vertebra. Osteoporosis is believed to result when the body is unable to form sufficient new bone, when too much old bone is reabsorbed - or both.

According to the U.S. National Library of Medicine, the leading causes of osteoporosis are a drop in estrogen in women at the time of menopause (over age 50) or a drop in testosterone in men over age 70. Other causes are chronic rheumatoid arthritis, chronic kidney disease, taking corticosteroid medications every day for more than 3 months, a history of hormone treatment for prostate or breast cancer, low body weight, and too little calcium in the diet. Often persons who have osteoporosis have no symptoms until they develop some type of bone fracture. Since osteoporosis is such a serious condition, drugs to control it have become widely prescribed. Brand names include: Acotonel, Aredia, Boniva, Fosamax, Zometa, Bonefos, Reclast, and Didronel. They may be administered orally or by IV. It has been reported that IV bisphosphonate usage results in a higher chance of BIONJ.

In addition to osteonecrosis, there have been reports of increased risk of femur fractures in women taking a bisphosphonate for more than five years. In fact, law-suits over this complication are ongoing. It is particularly upsetting to discover that a drug designed to strengthen bones actually is implicated as a cause in the fracture of one of the densest bones in the body. The exact opposite of what it is supposed to be doing! According to the literature, Fosamax, one of the most widely prescribed osteoporosis drugs, has been implicated as the oral bisphosphonate most commonly associated with  femur fracture.

Some oral surgeons recommend that a person discontinue bisphosphonates for a period of several months prior to undergoing an extraction. Certain blood tests may also reveal if a person is at increased risk for osteonecrosis. The CTX (serum C-terminal telopeptide test) can assess whether an individual might experience problems. It is reported that a result over 150 pg/ml indicates minimal risk following surgery or implant procedures. While 25% of the cases of BIONJ are said to occur spontaneously, 38% have been associated with tooth extraction, 29% with active periodontitis, and 3% with dental implants.

The literature now gives suggestions for treating an established case of BIONJ.  Treatment includes the use of chlorhexidine 0.12% mouthrinse to be “swished and spit” at least once daily, a drug holiday (if possible) for at least 6 months, and antibiotics such as penicillin, doxycycline and metronidazole for a period of time. Resolution of 90% of the cases are said to occur following this treatment. Prevention of BIONJ includes a drug holiday of 3-6 months (if the patient can tolerate going off the drug safely) prior to extractions or invasive procedures.

The problem for dental practitioners is two-fold. How do we provide information to our patients about possible problems, and when would it be “safe” to perform an invasive procedure? Some dentists are avoiding all extractions or invasive procedures on anyone taking bisphosphonates. Others are requiring the results of a CTX test and physician opinion prior to these procedures. Some are providing an informed consent form and discussion to anyone taking a bisphosphonate regardless of pending treatment.

With hundreds of women taking Fosamax and other drugs listed in this category, many of our patients may be at risk of developing osteonecrosis either spontaneously or subsequent to a dental procedure. At the very least we need to know, via our medical history questionnaire, which of our patients might be impacted. It is likely that more information will be available in coming years as to the best treatment for this devastating drug complication. Until then, prevention seems the best method to approach the issue.

Carol Tekavec RDH is the director of Hygiene for McKenzie Management.  Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department?  Email hygiene@mckenziemgmt.com.

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Nancy Haller, Ph.D.
Leadership Coach
McKenzie Management
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Dealing with Bad Behavior
Nancy Haller, Ph.D.

A few weeks ago, a JetBlue captain was locked out of the cockpit by his co-pilot after he began acting erratically on a flight from New York to Las Vegas. It was yet another episode in which airline crew members became agitated to the point they had to be restrained by passengers.

The magnitude of these incidents seems beyond the scope of a dental office, and hopefully your patients will never need to wrestle an employee to the ground. But at some point, one of your employees may behave badly. After all, people wear down. They get overwhelmed or preoccupied by things at home or outside of work. Sometimes, those commonplace stressful moments keep building until a meltdown happens - and it can happen to even the most professional employee.

Everyone has a bad day at work once in a while and it's important to address unacceptable actions promptly. If ignored, inappropriate behavior is likely to increase rather than just go away. Certainly there are some actions that will proactively minimize the chance of a major disruption. Here are some options.

1. Encourage Communication at Work
Discussing workplace stress and blowing off a little steam is important. Nobody wants to create a negative atmosphere with non-stop ranting about work, but talking about frustrations or challenges is healthy. Be attuned to the mood and mindsets of your employees, especially if you know they are experiencing some challenges outside of work.

2. Offer a Helping Hand
Though you clearly want to respect everyone's privacy, ask your employees if everything is OK. If he or she discloses a problem, encourage them to find solutions. Direct them to resources that will help with issues like child care, elder care and drug and alcohol dependency.

3. Assess the Workload
Meltdowns are also more likely to happen if a larger portion of the workload is resting on one set of shoulders. Even if you are incredibly busy, take the time to cross-train employees whenever you can. The investment of time pays off handsomely when those co-workers are able to take on a bigger workload.

If bad behavior gets repeated despite your efforts to curtail, redirect or stop it, it's time to take more serious steps. A meltdown could result in probation, suspension and ultimately termination. If the issue is important enough to trigger a meltdown, it should be a priority to address it starting with a serious and formal conversation that is done privately. The best location would either be in your office, with the door closed, or in a neutral setting like a conference or break room.

4. Communicate Expectations
Clearly define what you expect in terms of performance and behavior. For example, emphasize that while she has excellent technical skills, Suzie also needs to have positive interpersonal behavior such as helpfulness and cooperation with co-workers. As the Office Manager, she must build team identity and handle situations with diplomacy and tact. This requires listening well and seeking mutual understanding. Although she does not need to “like” everyone on the team, she absolutely must be respectful - no matter how upset she is. Yelling and throwing papers is not acceptable, bottom line.

5. Identify the Gap between Expectations and Observed Behavior
Be specific by focusing on changeable actions. For Suzie, these might include rolling her eyes when team members ask questions or suggest ideas, coming back late from lunch, making personal phone calls or surfing the internet during work hours, or talking in a loud and demeaning tone to others. Stay focused on what Suzie says and does in the most concrete descriptions.

6. Clarify the Rewards
Identify the benefits of meeting the expectations - i.e. job security, future opportunity and value to the practice to name a few. Be sure to express your appreciation to Suzie and emphasize what a great job she does with insurance and billing. Let her know that you want her to continue to work with you and that she needs to make changes in her behavior. 

7. Spell-Out the Consequences
Voice concern to Suzie that the way she has treated co-workers suggests she is not happy. Underscore that you want her to feel satisfied and to enjoy her job. Avoid ultimatums. Focus on the impact of poor performance, to the team and ultimately to the employee.

8. Allow Employees the Opportunity to Choose Their Own Path
One road leads to rewards, and the other leads to new adventures - including the option to leave. Your practice may not be the best place for Suzie if she can't get along with the other members of the team. Be truthful and kind as you lay out the choice.

Surveys indicate that workplace stress costs the nation close to $300 billion each year in terms of health care, work absenteeism and rehabilitation. More than ever employers can no longer brush aside the ever increasing concern of stress in the workplace, because it has become clear that mismanagement of this problem cuts deeply into profits and productivity.

Dr. Haller provides training for leadership effectiveness, interpersonal communication, conflict management, and team building. If you would like to learn more contact her at coach@mckenziemgmt.com

Interested in having Dr. Haller speak to your dental society or study club? Click here.

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