The case for case fees
Jeff Morley, DDS
When speaking to dentists around the country about retooling their practices to provide the most modern adhesive-based restorative care to their patients, the same question always pops up: "How do I turn my practice around and do things differently?" For those dentists interested in doing veneers, posterior ceramic restorations, and shifting their practice toward more patient-motivated cosmetic types of treatments, the answers may be found in unexpected places.
To be sure, clinicians will need to know how to cut the new tooth preparation and learn the techniques for using the latest materials. Beyond that, they won`t be doing nearly as much of that type of work in their practices unless they are able to set up new ways of treatment-planning and fee-development. For most of us, that will mean going to a case-fee format.
Developing fees
How does John Q. Dentist create a fee for a treatment plan? Well, over the last two years, I`ve asked that question to several hundred dentists attending my esthetic-diagnosis and treatment-planning courses around the country. This is what they told me: "I use my fee schedule." This, of course, is a reference to the typical UCR fee schedule that dentists submit to insurance carriers.
There are some variations from the theme. Many dentists have multiple fee schedules and they use the one that`s most appropriate for any given patient. I was surprised to learn the number of dentists who actually charge a lower fee to patients with insurance. This certainly raises the question of why dentists are willing to offer discounts on their services to multi-billion-dollar corporate payees, but expect full payment when it comes to dealing with private-paying patients. In any case, no matter which fee schedules are used, the schedules have one thing in common: they are broken down into specific procedures, each of which has an appropriate billing code. In other words, whether patients have insurance or not, they still are approached as if final acceptance of the treatment plan was coming from the insurance company and not the patient.
A typical scenario for determining specific fees for a treatment plan usually follows certain steps. The dentist does an examination and specific teeth are noted for caries, periodontal disease, and periapical pathology. Missing teeth are recorded and sometimes malocclusions are discussed. Some cosmetic concerns may be reviewed. Less frequently, wear facets and specific occlussal function are noted.
Next, treatments are broken down into line items with a price for each item. There usually is no apparent link between the whole and the sum of the parts. Fees typically are presented to patients in a way not too dissimilar from buying groceries at the supermarket. At the checkout stand, we put all of our groceries on the counter and the checker reads or scans the price of each individual item. If we change our mind about a particular item, we just tell the checker and the price of the item is subtracted from our total.
Similarly, when we itemize dental fees in our treatment plan, many cost-conscience patients look for items that can be "cut out" or compromised in an effort to get the price down.
If the examination is done during a hygiene appointment, the treatment plan may be highly abbreviated because of time constraints. Typical treatment plans developed during a hygiene exam are centered on replacement of an existing restoration or prosthesis, or focused on an emergency problem. For that reason, these exams involve only one, two, or three teeth and rarely are comprehensive in nature.
From there, the dental office may offer to submit a prior-authorization form to an insurance company, thereby subordinating the authority of the dentist and patient to make decisions. Treatment authority is handed to the third-party payee.
This system is fraught with problems.
Itemized treatment fees
The primary problem seen in itemization of fees is that rarely will the dentist fully account for all of the different procedures done on behalf of the patient. Services that fall through the cracks include not only clinical treatment, such as enamelplasty or tooth-contouring fees, but also work done on behalf of the patient while the patient is not in the office. Mock-ups, analysis of records to prepare for appointments, and work done in the office to set up lab procedures rarely are accounted for or receive compensation.
If you look closely, many things are done during a typical treatment sequence that do not have specific codes on a fee schedule. That can translate into an underestimation of the time and effort required for a successful result. Sometimes, if a given treatment, diagnostic record or analysis, task or function does not have a specific code or line item on an insurance schedule, we erroneously believe the procedure does not exist and that no compensation is due.
Without compensation, there is a built-in disincentive to perform procedures that might improve the longevity, esthetics, and final outcome of a given case. The ultimate loser is the patient and the immediate loser is the dentist because treatment becomes compromised. This problem becomes more critical when doing cosmetic dentistry because many of the procedures are not covered by most insurance plans.
Developing a case-fee program
(1) Meet new patients before offering treatment plans - When seeing a new patient for the first time, listen attentively to the patient`s problems and expectations, but do not offer a treatment plan. After hearing what the patient wants, suggest those diagnostic records required for a thorough analysis of the patient`s condition and treatment options. If the patient is in need of emergency care, it is appropriate to do limited treatment specifically for the emergency. All other treatment should be deferred until complete diagnostic records have been taken and reviewed. The goal of the first appointment is to schedule time for the taking of complete diagnostic records.
(2) Do not treatment-plan during hygiene appointments - When possible, do not schedule new patients for hygiene during their first visit to the office. Even in the case of existing patients, the hygiene appointment probably is the worst time to develop a plan for any type of treatment that involves more than one or two teeth. When the dentist literally is running between rooms mixing hygiene checks with other treatment, things are too hectic to fully address comprehensive patient treatment. Cosmetic concerns and occlussal analysis are areas that are most likely to be glossed over when treatment decisions are made on the fly. In such cases, the patient should be rescheduled so that complete diagnostic records can be taken.
(3) Take complete diagnostic records - There is no substitute for having all the information. This is one area where shortcuts can lead to improper treatment, incomplete treatment, and negative surprises during the course of treatment. Complete records might include full-mouth X-rays, complete intraoral exam, a photographic survey (as prescribed by the American Academy of Cosmetic Dentistry), periodontal charting, models, mock-ups, and occlussal registrations. For those patients who balk at the idea of a comprehensive diagnostic step before treatment, consider this: If they do not see the value or want to pay for records, they probably will not appreciate or be willing to pay for comprehensive treatment.
(4) Analyze those records for ideal treatment - Only by accumulating all necessary information, and dedicating time to review this information thoroughly, can the dentist fully analyze everything that must be done. Cosmetic problems are best seen through properly mounted models. Contemplated treatment must be analyzed in advance for esthetics and function if there is any realistic hope of creating predictable restorations. Thorough analysis of diagnostic records almost always reveals additional treatment required to solve problems. Dentists who perform this step typically have more successful treatment plans with larger case fees.
(5) Develop a treatment plan that includes all steps -
When developing the treatment plan, care should be taken to inventory all of the steps required to successfully implement the plan. This inventory would include the teeth to be treated as well as cosmetic periodontal procedures, custom provisional restorations, teeth to be reshaped, equilibration, build-ups, mock-ups, tooth-whitening, and protective bite splints. All procedures must be accounted for and factored into the case fee whether or not they are covered by insurance.
I Present a complete treatment plan with a case fee ? Once a comprehensive treatment plan has been devised, a single fee can be attached to the plan that represents the summation of everything that must go into that treatment plan. A typical case-presentation appointment would include a discussion and review of the diagnostic records, with an explanation of the dentist?s findings. Treatment would be discussed in detail with special emphasis placed on how treatment recommendations are directly keyed to solving problems discovered during the diagnostic step and subsequent analysis.
A single-case fee would be explained for this treatment plan, preferably by the dentist, and the risks and benefits of treatment would be weighed against the risks of no treatment.
This method of developing case fees outlines an approach that is successful in treating more comprehensive cases while encouraging patients to take responsibility for the care and condition of their dental health and appearance. If the dentist expects to be reasonably compensated for his or her time ? especially in the case of multiple-unit and cosmetic treatments ? utilization of the case-fee approach can produce better results. At the very least, developing case fees gives each patient the opportunity to accept well-thought-out, comprehensive care.
