With the right communication skills, you can strengthen the doctor-patient relationship while answering patients` toughest questions.
Marvin H. Berman, DDS
Sometimes, the beginning of a successful patient-doctor relationship can begin with a phone conversation. You get a phone call from someone who has been referred to you by another patient, a friend, or a colleague. This person wants to make an appointment, but first there are some questions he or she wants to ask before making that appointment. This is an opportunity to make a good impression ... so don`t blow it! Turn on that "phone smile" ... that "so-happy-you-called" voice. Listen to what the caller has to say. Don`t jump into the middle of his or her thoughts.
Frequently, the prospective patient wants to complain about his or her last dentist. Don`t let yourself get hooked into that scene! You don`t enhance your status by tearing down a colleague. Keep any negative thoughts to yourself; at least until you`ve had a chance to meet with the patient and do a thorough examination.
Caution: Don`t express a definitive diagnostic opinion over the phone. People often will call, asking for professional advice on the phone, hoping to get the information they seek without making an appointment ... and preferably for "free." It`s so tempting to express your thoughts, because you feel you know the answer. You`ve heard the question a million times. But wait until you`ve seen the patient! Once you`ve said something off the top of your head - sight unseen - it`s difficult to take it back. There is nothing wrong with saying to a patient, "Mrs. Wilson, I could give you my gut feeling off the top of my head, but that would be a disservice to you. Please, come in, so I can look at the situation and give you the full benefit of my professional expertise."
The same principle goes "double" when someone calls asking a front-desk person, "How much is a cleaning or how much do you charge for a filling?" The response should be, "It depends on the tooth and the condition. Every situation is different. But we`ll be happy to set up an appointment for you to see the doctor for an examination and he`ll answer all of your questions. Our fee for complete X-rays and an examination is ..."
The mention of a second opinion is worrisome to many practitioners. That little voice in your head says, "How can anyone doubt me?" There`s a tendency to get uptight and convey a defensive attitude toward the patient, especially when the patient is resentful and rude. Sometimes, this has nothing to do with you or the treatment you are proposing. More often than not, it`s about money. Cool it! Don`t burn bridges! After going for that second opinion, the patient may very well return.
So, with a smile, offer to send the X-rays and a copy of your treatment plan to another dentist of the patient`s choice. Keep in mind that the more thoroughly you`ve explored the alternatives with the patient, the less likely he or she will feel the need for another opinion. In effect, you`ve covered all the possibilities if you provide the patient with alternatives.
Your treatment decisions always should be based on what is in the best interest of the patient, not on what the patient`s insurance will pay. If the patient says, "I`ll have to see what my insurance covers," don`t get defensive! Instead, take the offense! My standard reply goes something like this: "Insurance was never meant to pay for medical or dental bills in their entirety. Insurance is meant to help defray some of the expenses. Look out the window! (On a clear day, you can see the Chicago skyline six miles from my office). You can see the Prudential building, the Equitable Building, and the John Hancock Building. No Berman building! Do you know why? Because I care about you and your dental health, and the insurance companies care about their bottom line. The less they reimburse you for your dental treatment, the more money they have left over to invest and construct buildings." In the words of Kojak, "Who cares about you, baby?"
Hopefully, you are not a dentist who is an agent or an employee of an insurance company! I would hope that you did not devote all those hours and years of study in college and dental school, only to become a vendor or a provider. So, basically my story to my patients is that "I`m the doctor." My years of experience and education qualify me to give patients my best educated opinion - i.e., "This is what you need. If you allow me, I`ll do my best for you."
In dental school, we were told time and again not to guarantee anything we do because of the many, many intangibles and variables involved in a dental procedure. But, there is something very antagonizing and disconcerting when someone says to me, "Of course, I can`t guarantee anything."
A nicer way to express that thought might be something like this: "Naturally, there are no 100- percent guarantees, because everybody is different. No two situations are exactly the same. But, I do guarantee that I will use all of my skill and knowledge in caring for you." What more can you ask?
Let`s talk business
Now that the patient-doctor consultation is complete, the responsibility for carrying the ball from this point shifts to the business assistant, business manager, or front-desk person. Hopefully, the doctor has impressed the patient with a warm, caring attitude and has inspired confidence.
I never discuss financial specifics with the patient. I don`t want to be directly involved with the day-to-day money talk. I discuss the nature of the treatment and the business person reiterates the plan of treatment and focuses on the charges and methods of payment. The transition between the doctor and the business assistant at the front desk must be seamless.
Any confusion between the two individuals is symptomatic of an office that doesn`t have its act together and diminishes patient confidence. The doctor and the financial person should review the treatment plan and make certain that both are on the same page.
I spoke extensively about the front desk as the power plant of the office in a previous series of articles in Dental Economics. The staff member at the front desk or the office manager should be knowledgeable about dentistry and comfortable with the terminology. She should feel a personal sense of pride in you, the doctor, and what you represent professionally.
Perhaps, most importantly, from a practical point of view, she must have the pleasant personality and poise that gives them the confidence to define the treatment plan and transfer it into the financial arena in a courteous manner. To put it in plain English - she has to be able to talk turkey about money, without hesitation or guilt, and without unduly antagonizing the patient.
If the front-desk person does her job correctly, a clear message is conveyed immediately. That message is that the doctor is concerned about the clinical aspects of the patient`s dental health and the front-desk person`s primary focus is the business aspect of the relationship. So, when a patient calls and complains to me about that "##@**#@! person at the front desk who only cares about money," I can, without hesitating, say, "That`s right, that`s her job to care about the money!"
The translation of the doctor`s grand vision into a meaningful financial arrangement is a crucial office operation. The insurance companies want to see a claim form with each service itemized, coded correctly, and a fee attached. So, although we encourage full payment at the time of service - whether the patient has insurance or not - we still assist patients with the submission of claims to their insurance company for reimbursement. We try to get away from the "piece-work mentality" and help the patient budget payments to coincide with each phase of treatment.
A philosophical statement
To disregard insurance altogether and not take into account family financial circumstances is an elitist attitude - it identifies you as someone who is out of touch with the real world. I provide care for families whom I know cannot fit into a "pay everything upfront" mold. The key to being a good doctor and a good businessperson at the same time is to get things straight, so that there are no surprises. Some families are on stringent budgets. Many women are left alone with children to support. There are families where the breadwinner is not working currently because he`s going through chemotherapy or radiation treatments for cancer. In other words, no matter how tight you`d like to tie up the package, exceptions do exist. Identify them and behave accordingly.
By the same token, our practice is not affiliated with any managed-care systems. HMOs, PPOs, and all of the other "O`s" are abhorrent to me. Interestingly enough, however, patients who cannot be treated effectively by dentists operating within managed-care plans often are referred to me to be treated at my usual and customary fees.
Standard financial procedures
Our office has been computerized for the past eight years. Computerization adds considerable efficiency and speed to any office operation, but don`t ever make the mistake of losing the human touch - especially when you`re discussing business!
The business-office person should review a hard copy of the treatment plan with each patient, covering everything the doctor has presented during the private consultation. She should discuss each treatment procedure, reiterating the "what" and the "why" and concluding with the "how much." She should then add up the charges in full view of the patient.
The business staffer should determine the number of visits required to complete the treatment and convey the strong message that payment must keep pace with the treatment. When the treatment is completed, payment should be finished as well.
Insurance is discussed last, because we want to emphasize to the patient that the diagnosis and treatment plan and fees are not based on what a third party will pay. Discuss insurance coverage, copayments, and deductibles, etc., at the end of the appointment.
Our first choice is for patients to pay in full for services rendered at the time of treatment. Our office gives them a statement to submit to their insurance companies for reimbursement. The second choice is either that the insurance covers all of the cost of treatment or that insurance covers a portion of the treatment and the patient pays the remaining amount. Waiting to see what the insurance company will pay and then billing the patient is out of the question.
Patients are asked to sign the treatment plan. They receive a copy of this document, which acknowledges that we have an understanding that we will proceed as stipulated. This document is not legally binding, but in case of any discrepancies, what we have in writing serves as a point of reference.
Payment is collected for services rendered at the initial visit. That visit may include a prophylaxis, fluoride treatment, and complete X-rays. If everything has been agreed upon, an appointment or a series of appointments are made to begin the treatment outlined in the treatment plan. If the initial visit is an emergency situation, we provide the necessary treatment to solve the immediate problem and then we present the overall treatment plan at the next visit, when the patient is more relaxed and the emergency crisis is over.
Note: Make certain you`ve covered all the details with the patient. Special discounts or professional courtesies or payment arrangements are noted in the treatment plan and verified with the patient. We try to eliminate as many of the "you never said that," or "I didn`t know that" situations as possible. If there are any discrepancies, give the patient the benefit of the doubt or calmly clarify any misunderstanding to the best of your ability. As you`ve heard many times before: "It`s not what you say; it`s how you say it."
Still another useful tip
There must be an overall atmosphere of friendliness and courtesy in your office. Our world today has become so numbers-oriented and computer-driven. Phone calls are answered by machines ... machines speak to machines ... computers talk to computers. The human factor is gradually being expunged from our lives. While you`re presenting the facts and figures to the patient, it`s imperative to establish a personal relationship. Get to know the patients and what`s going on in their lives. There may be illness in the family or an upcoming wedding. Maybe your patient is expecting twins.
You have to understand that there are other things going on in this person`s life that could mitigate his or her willingness or ability to proceed with proposed treatment. Put yourself in the patient`s place and ask yourself, "What would I do? What would I be feeling?"
It would be simple if we could just say to a patient: "This is what you need, and this is how I`m going to do it, and this is how much it`s going to cost." The patient would then say, "O.K. Great! Here`s the money! Let`s do it!"
But we all know that`s not how it works. There`s a story to tell, and you have to tell it in an interesting, enthusiastic, sincere, informative, and confident manner. We have to educate our patients to enable them to understand and accept what we`re proposing to do.
Whether you like the word salesmanship or not, you are selling yourself. However, with that successful salesmanship comes the moral obligation and responsibility to deliver what you`ve promised. The patient, in turn, has the responsibility to meet his or her moral and financial obligations to you. It`s a partnership.
One thing I know for sure. At the end of each day, you should be able to look at yourself in the mirror and respect the person who`s looking back. Until we meet again, this is Dr. Marvin Berman.