Articles By Fred

What are the best ways to deal with chronically late and repeat no-show patients?

Knee jerk reaction: Dismiss them from the practice.
Long answer: Read on...

In my experience, 23 years this summer, I can't recall having worked in an office where patients are NEVER late, or NEVER miss their appointments. It's foolish to think that ALL people are conscientious and keep their appointments; events happen in people's lives that prevent them from following through on their commitments.
For instance, haven't we heard of the patient who is scheduled, and confirmed, for an appointment that doesn't show up? The nerve… Only to find out that they were detained unavoidably at work for a meeting that may have more severe consequences than a tooth going south; like losing their job. Something may have occurred that we didn't hear about. Let's take a listen…

Patient's Boss: "Mary, we have an emergency meeting this afternoon, it starts in five minutes; grab your things, let's go."
Patient: "Gee, boss, I have a dental appointment, and it's real important that I go, I promised; and they already confirmed my appointment yesterday."
Patient's Boss: "Mary, what part of "emergency meeting which starts in five minutes; grab your things, let's go" did you not understand? I'll make it real simple, you choose: Meeting - keep job, Dental appointment - lose job."

Okay, all kidding aside, there are things we can control in this process, and things we cannot. When offices focus on the things they can control, kept appointment rates increase, failed appointments decrease, and patients by and large will arrive on time; sure, not always, but improvement is the idea here.

Before I lunge into providing some quick and useful ideas for integration into existing systems to improve kept appointment rates, here is another quick case study as an example of what not to do. During the first few weeks of a consulting engagement in an office I worked with a few years ago, the team showed me the following letter, received recently in the mail:

"I am sending this letter expressing my disagreement with your current policy of charging $45 for a patient that has missed an appointment.
On several occasions my daughter waited past the originated appointment time to receive your services. Additionally, we have never been past due on an account for your services.
Enclosed is the payment that you have requested. However, you are at a great loss, for my daughter will never return for your services nor will we recommend your services simply because I feel you have little value for a good customer.
Recently, my family moved to a new home. Apparently, the original appointment card was lost in the move. However, this letter is not intended to make excuses. It is simply to voice my opinion on your policy and my perception of your lack of appreciation for a good customer."

The team asked me what they should do in response to this letter from a patient of record. We pulled the chart to look into past events and discovered the mother and daughter had been patients for around 19 months. During the first six months, a chart entry indicated that they failed an appointment without notice. An entry on a later date indicated the mother called apologizing for not keeping the appointment due to car trouble. Okay, apology accepted, onward to better health.

A year passes with multiple entries indicating treatment for the daughter and mother; kept appointments; low or no balance due on the account. A chart entry was made about a month prior to receiving the above letter, about 18 months from the date of their first appointment. The entry indicated: "Failed appointment without notice - second occurrence, failed appointment charge issued, $45."

It gets better. When I asked if the reference in the letter about running late was true, the team members acknowledged they run late, constantly. Even though the reminder card was lost in the move, the family had mentioned that buying a better car was secondary to their children's dental health.

Uh, oh.

Seemed to me the office violated one of the fundamental principles of good appointment scheduling: Respect other people's time before you expect them to respect yours.
So, lesson number one: Be on time; don't make people wait. Also, avoid, as much as humanly possible, changing an appointment to make the day better for the office.
Gone are the days, I certainly hope, where we try to move people around because of holes in the schedule, due to cancelled appointments on short notice, or try to move patients up in the day so that we can leave early! This may backfire. There's nothing wrong with trying to make the most of your day and be as productive as possible, but when one takes the point of view of the patients, it may be an inconvenience to them to change the day or time of their appointment; we're all busy!

Okay. Let's be proactive and manage this situation so that we reduce the number of people that are chronically late and those that fail their appointments.

1. Respect other people's time. Stay on schedule, and make every effort to run the office in an orderly, professional manner so that appointment times are in line with the clinical treatment and skills of the providers.
2. Be polite and flexible, but firm and businesslike. Patients learn quickly if a receptionist handles the issue with tact and diplomacy. Example, "We missed you at your appointment, but it's good to know you'd like to make another appointment and complete your treatment. Let's find a date and time that you know won't conflict with anything else and that you'll be able to keep."
3. Listen to the patient's side of the story. There may be a very good reason why the patient didn't attend the appointment; hear it out. Then, decide based on your philosophy and what you've decided as an office if the reason is acceptable. If it is, move forward and re-appoint; properly. If it isn't, make the decision to dismiss the patient instead of facing the inevitable - chronic no-shows and cancellations!
4. Be nice. Patients may feel uncomfortable canceling during the confirmation call to avoid confrontation with an abrupt receptionist. Result: No Show.
5. Treat each case individually. Is there a clear-cut answer? No, but you can work within guidelines. Establish a foundation of good patient services and communication skills.

Dealing with patients who are late for their appointment:
When someone comes in late, have a conversation to let them know:
Team: "Mr. Herbert, hello, how are you?"
Wait for a response, knowing that they may provide you with all the ammunition you need.
Patient: "I'm fine, thanks."
No admission of guilt, even though they're 20 minutes late!
Team: "I noticed your appointment time was at 2:00, was that the time you had?"
Stop and wait for a response.
Patient: "Yeah, I got caught in traffic."
Team: "Boy that can happen around here, that's for sure. Let me see if we still have time to complete your treatment."
Leave the front; walk away. Check and see if in fact there is time to complete the treatment without inconveniencing the patients already scheduled.
Team: "We can still see you; but we'd like to stay on time as a courtesy to the patients later today. We may not be able to complete everything we had planned. In the future, if you'd be so kind as to do what you can to be here on time, we'd appreciate it very much."

Handle this professionally; but be direct. Let the patient know it's not okay for him/her to be late and try not to chastise or belittle him/her. If the patient could care less, and doesn't respect your time or other people's time, consider dismissing him/her as a patient. Standing firm on this is tough, but in my experience, there's a difference between letting patients run the office and you running the office.

Oh yes, and let's remember that delays happen, emergency appointments occur, and treatments may take longer than anticipated. Tips on putting out the fire when we may run behind:

When delays happen, talk to patients. Explain the delay, don't ignore it and behave as though it is a usual occurrence. Consider something like this.

"I'm sorry we're running late for your appointment. When our patients have a problem that needs immediate attention, we do our best to see them right away; hopefully without inconveniencing other patients. If the same thing were to happen to you, we'd do our best to see you immediately. Thanks for your patience."

A few final thoughts: Don't dismiss arbitrarily. Avoid patient abandonment issues by following this simple rule: do not dismiss a patient who has started but not yet completed treatment. In simple, what the dentist created must be completed. On the other hand, one may dismiss a patient who has a condition that must be treated, but has not started treatment. What nature created, you don't have to finish. You don't have to treat everyone.

Finally, be proactive. Work with the entire team to raise the bar on being on time, excelling in patient services, and enhancing communication skills. Put it all together to improve practice performance and rid the practice of patients who fail or are chronically late for their appointments.

I'm considering implementing an incentive bonus program.
Where do I start? Are bonus programs effective? What are the pitfalls?

Incentive bonus programs serve a valuable purpose for rewarding a team based on exceptional performance rather than just required duties. This sharing in the extra profit from successful operations is a generous gesture from the doctor towards the team, and adds energy to the business. Earning extra income for performance beyond normal expectations is an incentive for employees to contribute extra effort. However, there are pitfalls; but if constructed with careful calculations and good intentions, an incentive bonus may work very well.

When constructing an incentive bonus program, establish a Baseline level for calculating a bonus that must be met before a bonus can be paid. This number must be based on collections, or payments, after any refunds. Do not use production. Funding a bonus program must be done through actual money collected.

Since the bonus will be paid from income beyond normal expectations, the team needs to pull together as a unit to produce more. It has worked well to set a Baseline at the number that relates to how much the team is paid for expected productivity. Therefore, calculate the total gross wages paid, including pay for time off, such as vacation, and include payroll taxes. Exclude any wages and payroll taxes paid to the doctor. Make these calculations over a reasonable period of time, preferably six months.

Practices that control overhead typically hold salaries and/or wages, including payroll taxes to less than 25% of income, or collections. In this case, multiply total monthly salaries by four to arrive at a reasonable Baseline of collections for the bonus. Example: Total wages, salaries, and payroll taxes may come out to be $12,500 per month. A reasonable Baseline is then $50,000, because salaries would be held to 25% of income. Anything over the $50,000 may be considered available for bonus.

Pay an incentive bonus on 25% of any amount over the Baseline. A key point here is that controlling employee costs though the incentive program happens by only paying out 25% of any collected revenue over the Baseline. And, going forward, include any bonus paid when re-calculating the Baseline for future bonuses.

Since some months are longer than others due to the number of working days and vacations or time off for continuing education, a provision must be in place to even the playing field. Otherwise, the practice will pay out huge bonuses during big collection months, and suffer through reduced profit in lower collection months. To balance this, consider a rolling three-month average. Calculate total collections less any patient refunds for the previous three months and divide by three. This is your current total collections. Compare this number to the Baseline, and pay out accordingly if the total exceeds the Baseline. For the next month, conduct the same calculation for the most recent three months.

The abovementioned steps have worked well across most all practices when putting together an incentive program. Each practice is different in how much revenue is collected and operating costs. Following are some pitfalls and how to avoid them.

1. Employee turnover: Salary calculations may not represent the current salary level for calculating the Baseline; make adjustments to the bonus when employees are added or released since salaries will change as a result.
2. Fringe Benefits: Some employers offer extensive benefits beyond regular pay. If the practice pays for health insurance, vacation, holiday, sick days, disability, retirement contribution, etc., it may not be financially feasible to offer an incentive bonus in addition to the extra benefits.
3. Keep bonus pay at 25% of Baseline to control costs: To illustrate, when bonuses are kept at or below the 25% range, mathematically the total of salaries including bonus going forward will remain below 25% of total collections.
4. Cap on the pay out: A good rule of thumb is to limit the pay out of the bonus to a dollar amount; say $500 per employee, if on a monthly bonus. Reason being, the employees are given added income for their performance, and the practice can re-invest extra earnings into operations to retire debt, purchase more equipment, continue a successful marketing campaign, etc.
5. Provisions for slower collection months: There must be an "equalizer" for those months that the office may not collect enough revenue to meet general operating costs. A rolling three-month average is a sensible solution.
6. Quarterly Baseline Revisions: Keep an eye on payroll, bonuses paid, payroll taxes, wages and salaries quarterly. Make minor adjustments if these numbers begin to fall out of the healthy ratio of 25%. Again, exceeding the Baseline in collections, paying only 25% of collections over the Baseline, and capping the pay out will prevent the numbers from jumping out of the healthy range.
7. Qualifications: Consider placing qualifications on the incentive program. Here are a few:
   - 90 days must pass before new team members are eligible for the bonus system to calibrate their contribution and their part of payroll
   - Employees must be active employed members of the practice at the time of the pay out
   - Termination, either voluntary or involuntary, negates participation in the program immediately
   - Any manipulation of the appointment book or payments to influence the bonus will cause the bonus program to terminate immediately
   - Any material change in personnel (adding or reducing staff) may cause the program parameters to change
   - Pay out of the incentive bonus will be done at the next pay period following the end of the month

In conclusion, an incentive bonus program is only as good as the team and systems in place. Great communication skills, outstanding patient services, and a team working cohesively will lead to more income, profit, and will ultimately make the bonus program work.

"How do I handle a situation with an employee who's gone way over our quota of sick days as outlined in our employee manual?"

This question provides insight to the management style of the specific dentist or office manager who submitted the question. The fact that the office manual was referred to in order to handle this problem shows an office that is trying to follow policy, yet has a compassion factor in that the employee has been allowed to go over the sick day quota and is still employed. Compassion is a beautiful thing, but too much compassion may backfire.
Once a standard has been set, by deviating from the employee manual and allowing an employee to take additional sick days, it is difficult to return to a sense of normalcy. How fair is it to allow one employee to behave as he/she wants without letting other employees do the same?
At the end of this article I have included examples of how a sick day policy may be written. It details creative ways that an employer can help out the employee who truly needs time off because of illness. It is inevitable that employees will need time off due to the flu or to care for a sick child or family member. The general rule is be consistent with the written policy regarding sick leave and the number of paid and unpaid sick days allowed per employee.
The employee may need time off for an extended illness or injury, in which case a leave of absence may be more appropriate. Make sure the employee manual details a leave of absence policy for such occasions. Please note that the Family and Medical Leave Act will affect companies of 50 or more employees. The Act protects employment rights of individuals who are facing certain family situations requiring absence from work, such as childbirth or adoption, care of a seriously ill parent, child or spouse or their own serious illnesses. For companies with fewer than 50 employees, a fair and sensible policy is in line with good management.
The dental office relies on each team member to be present in order to function effectively. The office may no longer function as a well-oiled machine when a team member is absent or ill. Unfortunately, patient services may suffer as a result. Additionally, there is an added cost in finding a replacement on short notice; another little something that employers detest.
If an employee abuses the sick day policy, this can be considered misconduct and the dentist or office manager has a valid reason for disciplinary action. Oftentimes, in this day and age, discipline comes across as a negative action. Disciplinary measures should be instead thought of as a tool for learning and improving job performance. Without evaluating and providing feedback to employees, mistakes or poor work would never be addressed. Discipline should not be considered punishment, but rather guidance. The main goal is to guide the employee to satisfactory, and eventually excellent, job performance.
Employee discipline should be carried out as soon as possible, never put it off or hope that the problem was an isolated incident. If there is a significant time lapse between the misconduct and discipline, either the employee or employer may forget the specifics of the incident, or a message will be silently sent that the problem wasn't that serious. That being said, if one honestly feels that the misconduct was truly an isolated incident, out of character for the specific employee who normally performs well, the disciplinary action should be less severe than with an employee who has a track record of poor performance and misconduct.
Disciplinary actions should begin as verbal counseling. Direct communication regarding the office policies and how the employee is not meeting the expected standards should be a first. The initial verbal counseling does not have to come in the form of a warning, but rather to try and establish why the employee is behaving in a manner that is not acceptable. When situations like this arise, ask, "Why"; as in, "Why the behavior?"
After establishing with the employee that a change in his/her actions is needed, document the initial verbal counseling in his/her employee file specifying the topic and date. If the misconduct continues, more severe disciplinary action should be taken in the form of a written document listing the misconduct, actions that will be taken for improvement of the problem, consequences if the misconduct continues (termination) and concluding with the signatures of both the employee and the dentist. Part of the action phase should be an evaluation within a set time period for discussion between the employee and dentist regarding how improvement has taken place; make sure you follow-up! It is best to create an open dialogue regarding performance rather than slapping the employee with termination if the problem has not been resolved.
Effective employee managers catch and improve employee problems or shortcomings before they escalate into serious misconduct issues. It is always best to prevent the problem from snowballing. Be proactive!

Template for establishing Sick Days as an employee benefit:
A new employee must work for months before being eligible for paid sick leave. Prior to this period, an employee will not be paid for any time off work for illness.

Employees of more than months will be entitled to days off for illness per calendar year with pay. After an employee becomes eligible, a prorated amount of days is given until the beginning of the next calendar year.

Sick time will be cumulative up to a total of days. The {office manager/doctor} keeps records of sick leave. Unused sick days are not cumulative; they do not rollover or add onto the next years sick days. Unused sick days are not payable days upon termination from the company.

{OPTION}
Unused sick days {are/are not} payable at the end of the practice's fiscal year.

Days off for illness exceeding the number of paid sick days may be taken from vacation time, if any days remain. After those paid-leave days are gone, no compensation will be received. Persons ill for a period of time may take a leave of absence for up to days upon the approval of the Employer.

Dentist, doctor or other medical appointments which require an employee to come in late or leave early for a particular day will not count towards sick leave if scheduled and approved in advance. However, an employee must be at work at least hours during the day. The employee must present a written document from the attending doctor's office upon request. We encourage employees to schedule these types of personal appointments on days they are not scheduled to work, if at all possible.

When can we throw records away, and how long are we required to keep patient records? Also, should we charge patients for copying records? If so, what's appropriate?

For the answer to these questions, I contacted respected attorney Jeff Tonner. Mr. Tonner has extensive experience with dental law in Arizona, and is a wealth of information on this subject.
According to Mr. Tonner, nothing in the statutes tells us how long an office must keep records. Each year, he interviews insurance companies he works with and asks them, "Have you ever had a claim come up that is longer than ten years between the work being done and the claim being made?" Invariably, the answer is no.
So, ten years is a good rule of thumb. The ten years begins after the patient was last treated. If the patient were to return after ten years or so, the records would be so old that it would be advisable, and sensible, to start fresh with new records. For all intents and purposes, one really couldn't rely on material that dated. After ten years, one would probably be safe in destroying the records. However, keep in mind that for minors, the statute of limitations doesn't begin until two years after the minor becomes an adult, age 18.
Mr. Tonner also relayed an interesting story regarding the only instance where a dentist was asked to produce records more than ten years old. The case involved an orthodontist who treated the patient as a minor. Some issues came up relating to Temporomandibular Joint Dysfunction when the patient was in his 30's. When asked to produce the records, the dentist went up in his attic, and lo and behold, actually found the records! And, he also had the right stuff written down to help solve the case in his favor!

Records Request:
In my experience, many offices handle the question regarding how to handle requests for records incorrectly. There is a correct way, and the answer is here!
Follow these guidelines when you are asked to duplicate records, or when you are requesting records yourself:

• Make sure the request is not ignored. Ethically, an oral demand should not be ignored; legally, an oral demand may be ignored.
• When requesting records, prepare a short and simple form stating that a request is being made, and the name and address of the intended designee.
• Even though some states do not require written authorization, with the initiation of HIPAA, written authorization is advisable. Allow for a signature line on the office's records request/release form.
• NEVER GIVE UP ORIGINAL RECORDS. Mr. Tonner clearly states, "The dentist owns the chart, but the patient controls access to it."
• "Records" may include many items, including the entire record. Always designate what records are being requested. For example when a person asks for their records, try to clarify: "By 'Records', do you mean your current x-rays?" If the answer is, "Yes", then copy only the x-rays. If a person requests the entire record, then the entire record must be duplicated. In addition, if a person asks for multiple copies of the entire record, then the request must be fulfilled, and one may charge an appropriate fee for each copy made.
• How much is "reasonable charge"? A good guideline is to consider the hourly cost in wages of the individual's time plus the hard costs (paper, x-ray film, etc.) to duplicate radiographs and any other records; say $20. It is not recommended to withhold records due to an unpaid balance or for payment to duplicate records. This may promote a board complaint.
• When may one charge for duplicating records? In Arizona, the Dental Practice Act states a charge can be assessed; but it does not clearly state that payment must be made in advance {A.R.S. § 32-1264}. On the other hand, the Medical Records Act {A.R.S. § 12-2291} states a charge cannot be levied against a patient when a healthcare provider requests records on behalf of the patient from another healthcare provider. This is the basis of the majority of the confusion in the dental field. When a patient requests his/her records be copied and transferred then yes, a charge may be assessed; not when another healthcare provider makes the request.
• Essentially, there is a conflict with the Dental Practice Act that says you can charge; it just doesn't specify when. The Medical Records Act says you can charge in advance. To be safe, inform the patient who is asking for their records that there is a charge, you will prepare a statement for the duplication costs, and duplicate their records per their request. But remember, if another healthcare provider requests records on behalf of the patient, then a charge cannot be assessed to the patient or the party requesting records.
• An event that happens often is when a patient changes doctors, and asks the new office to request records from the previous office. The new office contacts the previous office, asks for records on behalf of the new patient. The previous office cannot charge for duplicating records, and must honor the request for records to be duplicated and transferred to the new office. Another event that occurs is when a patient calls their current office, states they are changing doctors, for whatever reason, and would like their records transferred to their new office. At this time, a fee may be charged to duplicate records and made available to the new doctor or to the patient to take to their new office.

Following is an example of the kind of text to use on a form to request records from another office on the patient's behalf:
"We have been asked by {Patient Name} to contact you and formally request his/her records sent to our office. Below you will find his/her signature authorizing the duplication and release of his/her records.
Please honor this request at your earliest convenience."

Here is an example of what to send to a patient who requests records from their current office:
"Please make copies of my original records and have them delivered directly to me at the following address."
or,
"…send them to {Dr.'s Name/Practice Name} at the following address.
Enclosed is my payment of $20.
Thank you"

Handle the duplication of patient records intelligently by knowing the rules and regulations. In addition, be sensible with this issue; patients ask for records for a variety of different reasons. It may be that someday, circumstances may change, and they may feel the need to change dentists again. The way in which this issue is handled will either remain a positive experience in their mind, or a thorn in their side. You choose.

For more information on this issue, reference the Dental Practice Act {A.R.S. § 32-1264}, the Medical Records Act {A.R.S. § 12-2291, 2295}, and attorney Jeffrey J. Tonner at 602-266-6060. The Arizona State Board of Dental Examiner's (BODEX) website provides information online at www.azdentalboard.org.