Tips from a fellow traveler

April 1, 2000
Patients can come up with some creative reasons for missed appointments and nonpayment for services. Here are some solutions!

Part 3

Patients can come up with some creative reasons for missed appointments and nonpayment for services. Here are some solutions!

Marvin H. Berman, DDS

The doctor is finished with the private office consultation and/or the clinical treatment and it`s back out to the front desk. Do your thing!

Scenario No. 1

The patient comes in for a routine checkup and no further treatment is required at this point. Make sure to positively mention the good news about the patient`s healthy mouth or, in the case of a child, the beautiful smile. Set up a checkup appointment in the book and/or in the computer appointment scheduler. We set a specific appointment time rather than sending an "it`s time for your checkup" reminder. It makes it more definite. Collect the fee due for today`s visit, and/or get the co-payment, and/or make sure the insurance is current and will cover the full fee (if you accept insurance).

Scenario No. 2

Patient is here for an emergency visit. The emergency treatment has been performed - e.g. extraction, opening into the pulp of a tooth to relieve pain, or even something as simple as removing popcorn caught between the teeth.

If this is a patient-of-record and the problem was something minor, you may decide not to charge anything for the visit. In this case, you would just note the problem and its resolution. On the other hand, if surgery is performed, or root-canal treatment is initiated, or if caries is excavated and a temporary dressing is placed, a treatment plan should be generated and post-operative instructions given. Have a discussion of payment details and schedule the next appointment. Call that evening to check on the patient`s well-being.

Scenario No. 3

The patient is here for ongoing treatment. In this case, you schedule the next appointment and accept payment. Don`t forget the friendly small talk while conducting business!

Scenario No. 4

The patient is brand new to the office and has had a complete examination, including X-rays. The doctor already has had a discussion with the patient about the condition of the mouth. You have a copy of the proposed treatment plan. The doctor has discussed the clinical aspects of the treatment with the patient, but not the cost. As I discuss in my videotape, "Winning Friends and Influencing Patients," the doctor should not speak specifically about costs or methods of payment. The doctor should address the "whys" and "what-fors." The people at the front desk reiterate the doctor`s proposal, explaining everything that has been said in the private consultation. But now, a money face is attached to the treatment. From this point forward, the treatment is the responsibility of the doctor and money transactions or questions about payments or fees are in the realm of the front-desk person. Make certain that the doctor and the front-desk personnel are in sync, so the patient doesn`t hear two different stories.

Use the printed treatment plan as the basis of discussion. Define and explain all terminology and repeat again why the doctor feels that this choice of treatment is best. Itemize each procedure without suggesting that the doctor do "piecework." Say something like, "The treatment plan is composed of the following items and the entire total is $ ."

Don`t get involved in a discussion about doing the easy ones, the big ones, the ones that show in the front, etc. The doctor already has presented the case to the patient, emphasizing the patient`s needs. Patients frequently are thinking "money," not dentistry. Keep them on the right track. Explain definitively that the responsibility for the treatment lies with the patient and the doctor (part of the doctor-patient relationship) and not the insurance company. The choice of treatment and the treatment plan are not based on insurance reimbursement, but on the patient`s needs. Say it again if the patient is hesitant.

"We care about you."

Insurance was never intended to pay the doctor fee in its entirety. It was meant to assist with dental expenses. Patients will sometimes say, "If insurance covers it, I`ll do it. If not, I won`t." Don`t get defensive!

From my office window, I can view The John Hancock Building, The Prudential Building, The Equitable Life Building, etc., in the distance. We point these structures out to the patient and say, "You don`t see a Berman Building, do you? That`s because insurance companies are not in the business of caring for your teeth. They are focused on their bottom lines. The money they don`t give you to pay my fees goes into building buildings. What if insurance doesn`t cover both lenses in your glasses? What if you need your appendix out and it`s not covered? Does that mean you leave it there to rupture?" Try your darndest to take the insurance company out of the doctor-patient relationship.

Note: Make sure you have the patient sign the treatment plan. This doesn`t constitute a binding agreement, but it does serve as a formal confirmation that the patient has heard the story and understands the plan.

Discussing the treatment plan

Use the printed treatment plan as a reference when discussing finances. "These are your needs that the doctor and I have discussed with you and this is how much it`s going to cost." It`s as simple as that.

Remember that the doctor should not discuss money or payments. The doctor should be concerned with the clinical aspects of the patient`s treatment and the front-desk financial person should be concerned about making certain that the patient pays for the treatment required and rendered, preferably at the time of service.

In our office, we offer the patient several choices to help them meet their financial responsibilities. They are responsible for paying, not the insurance company and not the dentist. Money can be a sensitive subject, but not in our practice. If the discussion of financial obligations upsets the patient, you may as well find out upfront before you begin extensive treatment.

Anytime you purchase any kind of services or goods - from the least expensive to the most expensive - you are required to pay. Does the phrase "cash or charge" sound familiar? Payment plans are fine, but will the patient stick to the bargain? You are not a finance company or a bank. It`s so important that the doctor establish a warm and pleasant relationship with the patient. A patient who likes and respects you will be more likely to accept and adhere to the financial regimen. There is no better time to request payment and receive it than at the time of service.

(1) Cash, check, or charge the full amount at the time of service.

(2) If there is insurance:

x It must cover the entire cost of the treatment; or

x The co-payment must be paid at the time of service and the balance must be completely covered by the insurance; or

x The patient pays us in full and we`ll give him or her a statement to send to the insurance company or we`ll submit it for his or her convenience

(3) On very large cases, we offer a 10 percent courtesy if the patient would like to pay everything upfront. You`ll be surprised at the patients who jump at the offer when just a moment before they said they wouldn`t be able to pay. We also extend professional courtesies.

(4) If you`re dealing with an extensive treatment plan (and a large financial obligation), some patients may require a payment plan.. Offer them the option of a low-interest plan with a local bank to help them finance their dental needs. Remember, though, you`re a dentist - not a credit agency.

If the patient resents your persistence and you hear about that "#&*$*#@" at the front desk who only cares about money, the doctor must back up his or her financial person. Simply say, "That`s right. That`s her job to care about the money. She is the financial person."

By being diligent, you eliminate the necessity for multiple statements and minimize the begging and pleading for money after the fact. Hounding patients for payments and turning them over for collection puts you in a position of not only losing the money, but losing the patient as well. Get things straight from the start and save yourself a lot of grief later.

If you and your office staff are consistent about collecting at the time of service, you will notice a remarkably low payment delinquency. Because my staff is so programmed into tying up the financial loose ends, our office is in the enviable position to be able to offer professional courtesies. On numerous occasions, we have provided many needy patients with treatment completely free of charge.

Statements and billing

All statements in our office are sent electronically. Statements to insurance companies cannot be avoided. Insurance claims are sent out at the end of each day with the press of one button on our computer. You know right then and there if the claim has been received or not and whether the claim is valid. Claims can be rejected because of wrong numbers or wrong names or patient ineligibility. Be sure to check all information on each claim before you send it. Errors will result in rejection, meaning you will be charged twice for submission and payment is delayed.

Patient Statements: If you don`t ask for and receive full payment at the time of service, you are automatically forced to send a statement for services. All monthly statements are sent electronically. Electronic billing is inexpensive (approximately 60 cents per claim) when you consider printing the bills, the cost of the statements and envelopes, the labor expense and time, and the postage.

Post-operative courtesy calls: Calling a patient in the evening after any invasive type of treatment is an absolute must. Not only is it an act of kindness that shows a concern for your patients, but it also helps relieve your mind about a particularly troublesome case. Ask about such things as bleeding and pain.

"Have you had liquids to drink?"

"Have you eaten yet?"

"Does it hurt when you chew?"

"Are you swollen?"

If everything is OK, great! If there is a problem, why wait for a "middle-of-the-night" emergency phone call?

Make the conversation personal. Don`t sound like a tape recorder, even if you`re speaking to an answering machine! There should be a positive tone and a discernible smile to your voice. Remember that "care is not care unless it involves caring."

Little things to drive you crazy

Wrong day?

No appointment card?

Not in the computer?

The patient arrives in your office. "I`m here!" You look in your appointment book or your electronic scheduler and the name is no where to be found. "Can I see your appointment card?" The patient responds with, "I don`t have it." You could say, "I`m sorry. You`ve made a mistake. I have you down for next week." But then the patient might say, "I know it was this week!" Who`s right? Who`s wrong? Does it matter?

Solution: The patient probably is mistaken, but could it be your mistake? Look at the patient`s record. What was the appointment for? Could you possibly get something accomplished today? Was the appointment for a checkup or was it for the delivery and cementation of a five-unit bridge? That`s a a big difference!

You then might say, "Let`s at least try in the bridge to see if it fits" or "Have a seat and we`ll see what we can do." Remember: Compromise ... not confrontation!

Bounced checks: There always is some awkwardness when you get a check back for non-sufficient funds.

Solution: Don`t feel guilty about calling the patient. Simply say that a check came back NSF and listen to what the patient says. If this situation occurs with a long-time patient with a good track record, then accept the person`s apology and redeposit the check. Otherwise, simply say to the patient: "We cannot accept a check. We`ll need a money order or cashier`s check. There also will be a surcharge to cover our bank penalty charge (if there is one)."

"Oh my! I must have used my last check!": Yeah right! More people are walking around with a checkbook and no checks! One of our favorites is, "My husband must have my checkbook." Not very likely! Women usually hold the purse strings for the family.

Solution: "We`ll take a charge card."

Delinquent accounts

Our computer system generates an aging report each month that shows who owes money and for how long. Once a second statement has been sent, the patient is called. We don`t wait for 120 days. The longer the account is delinquent, the less the chance is that you`ll ever see the money or the patient for that matter!

"I want to speak to the doctor before anything is done." Sometimes a patient asks to speak to the doctor about something personal. Perhaps the patient is having second thoughts about going ahead with treatment. Sometimes it`s about money.

Solution: Try the old reliable - "Can I help you?" If that doesn`t work, tell the doctor that the patient wants to speak to him or her. The doctor then has to listen to the patient`s story and work things out.

Caution: If the issue is money or appointments - something that pertains directly to the front-desk personnel - do not undermine your staff. Instead, reinforce your office policy. If the question is about treatment, then it may be necessary to restate and explain your treatment rationale again. If the patient is complaining about one of your staff members, listen to the complaint and say, "I`m glad you told me. I`ll speak to her about it." If the complaint is that your front-desk person is "too money conscious," take it with a grain of salt. Respond to the patient by saying, "That is her job, you know, to be concerned about the money."

"Can you just do the bad ones?" Whenever you hear this question, you must realize that "it`s about money." If the treatment were free, you`d better believe that the patient wouldn`t say that. Emphasis has to be placed on the fact that we`re treating the whole patient and not just fixing a tooth. On the other hand, if some of the treatment plan is elective and poses no immediate health threat, then it can wait.

"You never said anything about a nerve treatment." Maybe you didn`t. But most of the time, people hear what they want to hear. The doctor has discussed the treatment with the patient. You present a written treatment plan. You explain it. The patient signs in. But, at the next visit, the patient remembers nothing.

Solution: Don`t get hostile. Simply explain it again, so the patient is comfortable and everyone is on the same page.

"I can`t come because:

1. My husband took the car.

2. I was called into work.

3. I have to take my mother to the doctor."

There are a million excuses in the Naked City. These are just a few of them. Separate the wheat from the chaff. It`s especially irritating when patients call at the last minute and you`ve verified the appointment the day before.

Solution: You have to know your customers! Is this a habitual criminal or does the story ring true? Mention the tardiness of the notification and the fact that you normally charge for a failed appointment. "But ... blah! blah! Please don`t do this again!"

"I don`t want X-rays. I don`t want fluoride. I don`t want mercury fillings. Do you sterilize your instruments?" In our office, we have preprepared written documentation (scientific studies) that identifies controversial areas about which some patients express concern. This, plus the explanation by the doctor, generally carries the day. If a patient is insistent about refusing X-rays, you must make it clear to him or her that treatment is compromised without the complete picture. If we`re dealing with restorations, or extractions, or any kind of irreversible procedures, it`s advisable to let the patient seek treatment elsewhere rather than compromise your ethics or the welfare of the patient.

"I`m going for a second opinion. Give me the X-rays." Don`t get defensive if the patient decides to go for a second opinion. You should have presented several treatment options that you considered and then explained the reasons why you chose this particular alternative for this patient. If the patient still desires another opinion, make a copy of the X-rays and treatment plan available to the dentist he or she wishes to consult. Then ... turn on that smile! The patient may very well be back! Many times, it`s not that a patient doubts your knowledge or skills. The patient`s focus may be on the money. Some patients are not concerned about quality. They`re just shopping for a better deal. If you`ve told the true story in a sincere manner, don`t dwell on regrets. You can`t unscramble eggs.


As dentists, our time should be spent doing dentistry and administering to our patients. We also have to be business people. We try to distance ourselves from the business aspects of our practices and entrust those activities to our front-desk personnel, but we still must maintain a healthy awareness of what`s going on.

Review the patient records. Check the income ledger against the computer totals. Look through the daily activity reports which include all treatment provided to each patient and a complete payment record for that treatment.

As each day begins, make sure that you touch base with your front-office personnel. This should include saying, "Good morning. How`s everything?" At the end of the day, since you have not spent much time with each other, have a short meeting to discuss any happenings or details that may have come up. Remind one another about things that need attention the next day and don`t forget to say "Good night." Don`t leave the office with any unsettled personal issues. Now is the time to talk about them.

Remember, long-term success is not luck. It`s a product of team effort - an overused term, but an under-realized goal! Everyone on the team should be communicating with everyone else. The doctor is the one who has the pulse of all the employees. You are the leader, (yes, the boss, if you will), a much- maligned title. You know the goals that you want to achieve and you must be able to convey your feelings to those around you clearly and succinctly.

The employee members of your team, by the same token, must be aware of the policies advocated by the leader and work in concert with him or her in the best interests of the practice. The fact that the doctor is not physically present in the front-desk arena for most of the working day means the people "up- front" bear an even greater responsibility to maintain the equilibrium of the office. If the front desk is the power plant, make sure that power is used effectively!

Here`s wishing you good health and continued success in the future!

For more information about this or to order his latest videotape course on "Winning Friends and Influencing Patients," contact Dr. Berman at (773) 764-0007. A biography of the author appears on page 12.

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