$1,400 for one tooth!

Oct. 1, 1999
Patients shouldn`t be expected to submit to treatment before they comprehend what the treatment is and why it is recommended.

Patients shouldn`t be expected to submit to treatment before they comprehend what the treatment is and why it is recommended.

Carol Tekavec, CDA, RDH

It happened again today. A friend called to tell me how annoyed he was with the dentist I had recommended to him. He had quite a few complaints, ranging from dealing with a disinterested front-desk person to being forced to listen to the dentist`s spouse loudly criticize a staff person in the hall outside of the treatment room he had been seated in.

His chief problem, however, stemmed from confusion over his bill. He began to read me what his statement said, asking me what the terms meant and whether or not the fees seemed reasonable. I asked him to find his treatment estimate and compare the explanations and fees from this document with his final statement.

He looked at me with a surprised expression on his face, and then told me he did not receive a treatment estimate! In fact, he told me that he had never had a treatment plan explained to him. He had no idea what procedures actually had been performed, nor what treatment still needed to be done.

I experienced the sinking feeling that I always get when faced with defending dentistry to someone who is unhappy with his dentist. Worse, this happens much too often! Why are there so many misunderstandings?

The dentists I know and recommend are excellent practitioners to whom I would feel comfortable sending any member of my own family. They are caring, interested, and quality-oriented. They hire only educated staff. Many of them spend considerable time and money attending continuing-education courses. They are "cutting edge" with new technology and techniques. They care about patients and staff. The particular dentist I am referring to in this article recently took his spouse and his entire staff, at great expense, to an out-of-state, three-day practice-management clinic, and made a commitment to return twice more this year. He wants his practice to run smoothly!

What is the matter?

While there may be many factors contributing to the dissatisfaction a patient might have with a dentist or dental office, a major problem is a profession-wide aversion to presenting a treatment plan and fees during a treatment conference before beginning treatment. Patients are submitting to treatment before they comprehend what the treatment is and why it is recommended. They are shocked and unhappy when they receive statements for what they consider to be huge sums of money for procedures that they do not understand and may not even believe that they need.

Present a treatment plan

No amount of time spent in a management course can help an office that will not commit to the practice of providing patients with a detailed treatment plan, fees, and financial arrangements. Patients forget the gentle care, beautiful restorations, thorough prophylaxis, and painless treatment they have received when they are faced with a bill that they do not understand.

Why are dentists reluctant to have a treatment conference with the patient prior to treatment? The number-one reason seems to be the fear of scaring the patient away. Dentists wrongly assume that if a patient knows what he/she needs and finds out what it is going to cost, the patient will never come back. These practitioners think they should get as much treatment done as possible before the patient can get out of the chair ... and out the door.

Fear of scaring the patient away also contributes to the schedule-breaking and new-patient-destroying practice of performing definitive treatment on emergency patients who have come in only to have pain relieved. The dentist diagnoses an abscess and feels compelled to complete the entire service while regularly scheduled patients languish in adjacent operatories. The dentist does not want this new patient to "get away." Often, emergency patients have a complete endo, a crown build-up, and crown prep accomplished before they even understand the need for a pretreatment radiograph. Three weeks later, they receive a bill for $1,400 for one tooth and they go crazy! Do they schedule appointments for complete new-patient exams and become referring patients for the office after this happens? Never!

Emergency patients should have palliative treatment only. It is the only way to build long-term rapport and trust. Would you agree to a serious medical procedure before you understood the need or the procedure, what would happen during the procedure, the recovery time, possible complications, and whether or not your insurance could be expected to cover a portion of the cost? Of course you wouldn`t!

Would you arrange for a vacation trip without finding out where you would be staying, how long it would take to get there, and how much the trip was going to cost? Probably not.

Would you take your car for repair to a garage, where, after you pointed out a loose door handle, you received a bill for a complete engine overhaul? Not likely! Patients react the same way to dental treatment that they do not understand and aren`t prepared to pay for.

Presenting a treatment plan and fees during a conference is a delicate process. It usually is as important as the actual treatment itself in ending up with a satisfied patient.

The second reason patients are not receiving treatment estimates is time. Dentists and their staffs are extremely busy. Taking time out to prepare a detailed treatment plan, fees, and financial arrangements takes time away from work at the chair. Management advisers tell dentists that they must be working at the chair, not wasting time elsewhere. Finding time to present a treatment estimate becomes a problem.

The third reason patients don`t receive treatment estimates is a lack of understanding about how to prepare and present the information. It`s a daunting task to organize a complicated case into a format that patients can understand. After the case is organized, it often is even harder to explain treatment recommendations so that patients follow the rationale behind the procedures. Even tougher is what I`ll call the "grand finale" - explaining fees and what insurance will and won`t cover!

So, what can we do? Patients must have treatment plans and treatment estimates. The best way to approach the process of providing this information is to divide the task into smaller steps.

Step one

The dentist should select paper charting forms or a computerized format for initial patient-data collection, pathology, and treatment recommendations. This sounds good, but what does it really mean?

(1) Write down all existing conditions.

(2) Identify areas of pathology and write them down.

(3) Identify treatment and write it down.

(4) Identify any alternatives and write them down.

(5) Prioritize treatment.

All of this can be done during the patient`s first appointment. Using a chart form designed to organize the information, the chairside assistant makes the notations as the dentist dictates his or her findings. In many cases, complete treatment recommendations can be identified right at the chair while the dentist examines the patient and goes over the radiographs. (The patient also is listening and learning during this process.)

Step two

Information from the initial data-collection form then is transferred to a detailed treatment-estimate form. This can be accomplished by the dentist or, more economically, by a knowledgeable auxiliary. The form should list all recommended services and fees, and, if appropriate, alternatives and their fees. This is the time to discuss insurance-payment limitations and patient-payment responsibilities. (On large cases, and even certain smaller cases, patients may appreciate insurance being sent in for a pre-estimate prior to the treatment estimate being presented. The patient has an idea what insurance probably will pay and, therefore, what his or her obligation will be.) If the dentist does not accept insurance payments, this also should be explained in detail at this time.

Step three

If there is time during the initial examination visit, the actual treatment conference and presentation of the treatment estimate can take place at the end of the visit. If there is not enough time, the treatment conference can be scheduled for a subsequent appointment, combined with other necessary treatment. (Patients who say "Just do whatever I need and I will handle the bill later" must have a treatment conference just like everyone else. These often are the patients who will later tell you that they had no idea what was going to be done and that they are unhappy with the results and the fee charged.) The patient should take home a copy of the estimate, while another copy remains in the patient`s chart.

Step four

Separate informed-consent forms relating to treatment recommendations also should be presented during the conference. Informed consent actually is a process, not a form. However, a signed form for certain procedures helps verify that the treatment was explained in detail. When is an informed-consent form appropriate? Current thinking indicates that any procedure that "is not commonly done or easily understood" should be explained and supported with a signed informed-consent form. With such a broad definition, many standard procedures in a dental office might require such a form. Don`t be afraid to go over possible complications with patients. In today`s world, people understand that most everything has its risks. Patients have the right to know all about their treatment and the right to make an educated decision. Give a copy of each signed form to the patient, with another copy retained in the chart. (A booklet of 26 sample informed-consent forms is available from Stepping Stones to Success.)

Step five

Transfer all information from the initial-data collection and recommendation to a treatment schedule that maps out the details of each and every appointment. This schedule should start with the first visit in the treatment sequence and go through the last visit. Be sure to list each appointment, the length of time needed, what should be accomplished, the doctor or hygienist the appointment will be with, and the fees to be charged and collected.

The last appointment listed for every patient should be for a continuous care or recall visit. Every patient in your files should have an active appointment or an appointment for a recare or recall visit. If a patient does not want to set up a recall appointment at the end of a series of treatment visits, be sure to make a follow-up card in your tracker system on this patient. Not maintaining recall patients is what erodes many dental practices. Use your computer, a card file, or a combination of both to keep track of patients. Use a treatment-schedule form to keep track of what needs to be done at each visit. Do not skip these important management functions!

(Charting forms to facilitate data collection, treatment-planning and organization, written estimates, and informed consent ? as well as a card Tracker System ? are available from Stepping Stones to Success.)

When this format is followed, appointments run smoothly because patients understand what is happening during their visits. After complete treatment estimates and conferences are presented, patients do not need to have root-planing explained by the hygienist or root canals explained by the chairside. They don?t argue over fees at the front desk with the receptionist. More time is spent during the first few appointments to foster understanding and rapport, encourage complete treatment acceptance, and facilitate subsequent time-conservation. When patients receive a statement, they can compare any fees that they do not understand with their treatment estimates, instead of angrily calling the office or phoning all of their friends. If questions arise, staff members easily can resolve them by consulting the treatment estimate.

The use of detailed data-collection forms that function properly, along with treatment-estimate forms, saves time and streamline a practice. None of the forms or the actual procedure of presenting a treatment estimate is very glamorous. However, the forms are essential in eliminating one of the most common, practice-damaging problems in dentistry ? the unhappy patient who does not understand his bill!