Ethical Scenarios and Responses
Michelle Strange: A Tale of Two Hygienists presents this week’s TIPisode: Quick and easy tips to keep you up to date and presented by the experts in the profession. Now, get ready for your unofficial TIPisode.
Teresa Duncan: Hi. This is Teresa Duncan with the Nobody Told Me That! podcast and also the soon-to-be-published Chew on This podcast. More news about that later.
I’m here today to talk to you about some of the conversations we have to have with patients that are ethical and sometimes borderline on shady on the patient’s part. We have to have the right answers. We just can’t wing it. We should be thinking about this prior to actually taking these conversations on.
I wanted to give you three different examples. And, if you ever want to shoot me an email, feel free to do that with any other examples, and hopefully I can help you wordsmith your way through that.
Now, the first one that you normally get — and I’m thinking every single one of RDHs that are listening have had this question, which is “but can’t you just bill it as a cleaning it rather than the 4910 after you had the scaling and root planning?” The reason that they’re saying that is two-fold. First of all, they’re concerned about the cost, and of course, who isn’t? And then the second one is something that we need to pay attention to. The second one is that it may not seem like a more of a cleaning to them. And so there’s a couple ways to approach this.
Let me give you the verbiage first. The first thing to say is “I wish I could do that. Unfortunately, what we did was very different than a cleaning, and according to the ADA” — see how I’m just putting this on the ADA — “according to the ADA, we are supposed to submit for what we actually did. I wish I could help you with this.” And, you know, you take that “I wish I could help you” tone, and you’re sympathetic, but at the same time, you’re not giving in. You know that it was different.
So first things first. The way to avoid this on the first part is when they are doing the treatment plan presentation, I would include — along with all the scaling and root planning, I would include the last phase to have two codes of 4910. So what that does is it reminds the treatment plan coordinator to mention that from here on out, although we would love to do what we used to do, which is a preventive appointment, we are now going to be doing a different kind of appointment since you’ve had to have treatment for the gum disease. That prompts them to talk about it and also takes care of the billing questions.
I’m a firm believer that the front office, the administrative team, should not handle clinical questions, and the clinical team really shouldn’t go into billing unless they have done this in the past, but really, it’s not your place. The reason I say it’s not your place is because you have better things to do, and also same thing for the admin. We can’t take the time to sit and explain ligaments and suppuration and furcation. We just don’t — we don’t have time to do that, so let’s keep it in our arenas. That’s going to make your life easier if we are able to go over the expected cost with the patient ahead of time.
Now, the second part is a little bit more soul searching. If you’re hearing this an awful lot, perhaps the process that you and your office is providing is not feeling different. If it doesn’t feel different, I see this from the patient’s perspective. When you’re performing the 4910, are you going over progress? Are you calling out areas of improvement? If you’re going beneath the gums, let them know that. You need to make it feel like it’s something different than a preventive appointment because that’s what they’re expecting. You’re probably providing it. They’re just not aware of it.
So be a little bit more forthcoming about exactly what you’re looking for. And that’s a great time to tie in why you did the procedure in the first place and how they can avoid having it in the future. Now, you can tell this means some conversation between you and the rest of the team to make sure that it’s all wrapped up in a bow.
The second ethical — this gets ethical — question that you are probably going to receive is “Well, I was never told this before. Why didn’t my office — my last office never told me this, so they must be really horrible. Should I call my old office and tell them that they should have caught this?”
Some patients are going to be very mad that their perio disease wasn’t picked up on, that a broken crown wasn’t picked up on. They’re going to be very angry. And your first inclination, along with mine, is “Well that’s because we’ve known that that office has sucked for years,” but you can’t say that. So what you have to say is “I’m really not sure what their process is. I can’t speak to that. But I want to focus on what I see right now, and that is that we have periodontal disease to take care of. We have gum disease we need to address.”
Now, they’re going to persist because they’re going to be angry, and rightfully so. They’re going to be angry that they thought they were healthy and now all of a sudden it’s going to cost a lot of money to get to where they already thought they were. We’re going to be sympathetic about that, and again just say, “I’m not sure what their process is. Perhaps they were looking at it. But from what I’m seeing right now, we have some work to do.” Take that tone with them.
Now, the one question that I’m going to go over here is something that can be annoying but also can be used as a great marketing tool. Have you ever had a patient come in and say, “You know, I spent so much money with you all. Why can’t I have this cleaning for free? Or why can’t I have bleaching for free? Why can’t I have this fluoride for free?” At first, you’re like “Jeez, this person wants everything for free,” but let’s think about it from the patient’s point of view. They probably spent a lot of money. If they’re asking you for this, they probably spent a lot of money.
So what I would do is, ahead of time, you may want to bring this up to the team and ask them is there any leverage that we can use when someone says, “I spend so much money with you”? If you think about the cost to provide a fluoride treatment, that is super low, super low, and your fee-for-service patients are going to really appreciate this. So, if you have that kind of wiggle room — and I know that when you’re a PPO office it is a little bit different, but honestly I think this is one of the most low-cost services you can give — I would say, “You know what, Mrs. Smith? I know you come here a lot. We talked about it this morning. We wanted to acknowledge that.” Or “We talked about it in the past, and we wanted to acknowledge that, so I’m happy to give this to you complimentary. I know that we’ve done a lot of work, and this is going to help you keep that from happening again.”
You know, in the end, we are in the business of making their mouths better, and if a little fluoride treatment is going to help make them feel better and it’s also going to be great for them, why not?
Now, the bleaching is going to be a little bit more tricky. You do have to decide as an office is bleaching something you offer? First of all, is this patient a candidate for bleaching? That’s really the first thing. But is bleaching something that you all already use as a marketing tool and a loss leader to bring patients in? If so, then this is a marketing expense because this patient will likely continue to see you because you’ve just created that bond with them.
If you don’t offer bleaching, then I would go back to the fluoride. I would go back to — perhaps they have some adult teeth, some permanent teeth. Maybe you did a bunch of crowns, but they still have one or two adult teeth. Offer to seal those for them.
Now, I don’t know what’s going on in your office as far as cost and your expenses, but I think that if you brainstorm with the doctor and the manager, you’ll be able to come up with something low cost that, should the question be posed to you, you have something to pull out. Or you could make sure that everybody knows about it, and then you say, “Look, go up front to Teresa. I know that sometimes she’s able to create some change in what we do for you as far as billing, so go up and talk to her, and we’ll make it happen for the next appointment.” But I think, honestly, if you’ve had this conversation as a team, you’re able to have this conversation with the patient.
I do know that our patients tend to expect top-level service, and you’re not going to get this question a lot from patients because, honestly, a lot of people just don’t think to ask for these. But, remember, if someone asks you for something for free because they’ve spent a lot of money with you, they like you. They want to keep coming to you. They’re just thinking, “Come one, man. I saw the bleaching ad in the waiting room. Why can’t I have one of those?” And, you know, you may want to just do that as a reward, as a thank you.
I just went through three of them. When it comes to other questions that are ethical and kind of border on shady, I want you to think about the patient and where they’re coming from. If it’s a good patient, someone that you’ve had in the past, maybe — or along history with — maybe there’s an education to be made. Maybe you need to let them know “We’d love to write off the co-payment amount, but unfortunately, we just can’t. It’s considered fraud.”
Or is it somebody that’s coming in really trying to get you to break the rules? That’s somebody that I would bring up at the next meeting and say, “You know, is this somebody we really want in our practice?” Because the people — and I’ll tell you this from an admin point of view. The people who ask you to do illegal actions such as writing off co-payments or changing the date on billing, they are the first ones to report you to the insurance carriers or to the board when they are unhappy because they are used to getting around the rules. So be really careful about that type of patient. I can tell you that with 100 percent conviction when I see that pop up, when that behavior or those questions pop up, they are on fast track to be dismissed from our patient for whatever reason we can find. We just know it’s trouble brewing.
I hope all of this was helpful. I hope that you don’t get many shady or ethical questions. I hope this is one of the most useless in practical application podcasts that you have. But, should you need to use it, I hope it is most useful.
So, again, my podcast is called Nobody Told Me That!. I go over insurance issues, management issues. And we also have — my co-host Kevin Henry and I, we also have an upcoming podcast called Chew on This where we’re going to go over the stories of the day, the recent stories in dentistry, and give you our take on them, and give you something to chew on.
Until next time. This is Teresa Duncan. Thank you for your time.
Michelle Strange: We hope you enjoyed this week’s TIPisode. Be sure to reach out to our guest experts and let them know how helpful their tips were. Follow A Tale of Two Hygienists on Facebook, Instagram, and head over to ataleoftwohygienists.com and subscribe to our newsletter. You can also email us at email@example.com, and keep listening for more awesome content from your unofficial dental hygiene podcast.