Case Studies of Dental Practices

July 1, 1997
Case Profile: A general dentist has been in solo practice for nine years in a suburban midwestern town. The socioeconomic level of the area is average to above average. There is an even split in the practice between managed care and fee-for-service. Between the doctor and his two hygienists, the practice averages 31 patients per eight-hour day.

Sally McKenzie, CMC

Case Profile: A general dentist has been in solo practice for nine years in a suburban midwestern town. The socioeconomic level of the area is average to above average. There is an even split in the practice between managed care and fee-for-service. Between the doctor and his two hygienists, the practice averages 31 patients per eight-hour day.

We were called in because the doctor wanted to reduce staff in the business part of the practice from four employees to three. But he had no idea how to present this to his staff, nor how to convince the remaining three that they could handle the duties.

Symptoms: At 26 percent of income, gross wages far exceeded the industry-endorsed 22 percent. If that wasn`t bad enough, staff mindsets seemed to be OK with "twenty-something" performance ... patient retention drowning at an abysmal 29 percent and accounts receivable over 90 days at a dreadful 27 percent.

Observations: While the office had five computer terminals in the business part of the practice, there was no terminal at the check-in/check-out desk. In fact, there was no such desk! To add to the confusion of who sits where, when ... there was not one definitive job description for any of the four business employees. Phones were answered by whoever had a chance to pick it up. Although there was an individual primarily dedicated to scheduling, appointments were being made manually in an appointment book by each of the four auxiliaries.

The greatest inefficiencies, however, were in the way patients were dismissed, posting of charges and insurance. Here`s the scene: The patient would be dismissed to the office manager who we`ll refer to as Ms. Moneypenny. Signaling the patient to sit down with her at a desk which held a three-ring binder with all the fees from all the plans, Ms. Moneypenny stated the charges for that visit and any balance that remained on the account. While sitting with the patient, she attempted to collect that day`s fees as well as any unpaid balance.

When finished with this, she directed the patient to the "appointment secretary" to schedule the next appointment. Ms. Moneypenny walked the chart over to an insurance clerk who posted the patient`s charges into the computer. Insurance was filed by printing out a claim form, submitting it and putting a copy in a file A-Z ... awaiting payment. The insurance clerk posted all mail payments and insurance payments. As an insurance check was posted, she would retrieve the copy of the claim form, attach the EOB to the copy, locate the patient`s name on an "unpaid insurance claims report," pick up a "paid" rubber stamp and stamp over the patient`s name. Welcome to 1975!

In addition, the computer system was inefficient. By that I mean that, to access data, it took going to more screens than is the case with other systems. To make matters worse, office staff had been given minimal training on the system. The system also did not easily allow staff to enter in patient responses during phone calls for recall appointments or for delinquent account calls. Business employees were jotting down whatever patient conversation they could on report printouts.

Discussion: It takes approximately 10 minutes for one business employee to greet and dismiss a patient. In this practice, 310 minutes were tied up in an eight-hour day for one individual to process patients. That left a little over two hours in the day to do non-patient tasks such as answer phones, pull and file charts, confirm appointments, do billing, file insurance, fill cancellations, etc.

Since nonpatient tasks require at least half a day, one person cannot manage the required work. By putting two people in charge of processing patients - one quoting charges and posting and collecting money and the other scheduling - we would lessen the checkout process to five minutes per job description.

Technically, this practice could manage with two employees in the business part of the practice instead of four, if the current systems being used were more time- and motion-efficient. As this is not the case, a third job description was needed to effectively work and manage both the recall system and delinquent accounts.

Treatment Plan: Job descriptions, which reflect the ideas discussed above, make it clear that three individuals comfortably can handle the present workload in this practice. By eliminating one staff position, payroll will be reduced by $1,800 per month. By increasing overall production and collection, payroll expense should fall into the 22 percent range.

Here`s how it should play out: Having one individual responsible and accountable for making outgoing phone calls to retain past-due patients should increase patient retention far beyond the present 29 percent rate. Combined with that, the responsibility and accountability for making delinquent-account calls should reduce accounts receivable over 90 days from the present 27 percent to less than 18 percent. Having another individual accountable for "scheduling to goal" in the hygiene area should reduce and often eliminate the department`s present average of three openings per day.

Finally, the financial coordinator will have a terminal at her check-out position where she will be able to view any previous balance, post the charges and payments immediately and give the patient a printout of services that were performed.

In addition to the "must do" issues above, the practice would greatly benefit from new computer software which would provide easier access to patient information, allow for inputting patient conversations and eliminate the need to work from printed reports.

Sally McKenzie is a Certified Management Consultant and president of McKenzie Management, Inc., a full-service, in-office dental management consulting company with clients across the U.S. and Canada. She can be reached at (800) 288-1877; e-mail [email protected]; or visit her web site at

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