Articles By Fred

“Within the past year or so, I’ve noticed more people have had economic trouble and are slow in paying, or aren’t paying on their past due accounts. I’m hoping you can shed some light on how to handle this situation.”

It certainly is a sign of the times that people are experiencing troublesome economic conditions in their personal lives. This certainly impacts the dental industry, as we’ve seen some practices declining in revenue, laying off workers, and having a hard time gaining acceptance to treatment from patients. Even when patients accept treatment, making good sound financial arrangements may not be as dependable as in the past.
First step is to be sure the basic elements of the practice’s financial policy are strong and orchestrated in a consistent, professional manner. To review the three key principles of sound payment systems are:

1. Always practice financially arranged dentistry. Inform patients of the fee and make specific arrangements for payment before any treatment begins.
2. Don’t be a bank. Avoid making arrangements that allow the patient to make payments over time. Often, this is called an “Open Account”. Sending statements to patients hoping they follow through with the “three equal installments we arranged” without any sort of written contract or debiting method is setting the practice up for disaster. And, the “half at prep, half at seat” has its pitfalls also. Patients may not return for the final delivery because they don’t have the money. Offices must finish treatment that was started regardless of the patient’s ability to pay.
3. Offer flexible but firm payment options. Offer a variety of options that will meet most people’s financial needs. Consider a reduced fee for payment made in advance and a courtesy for cash payment, third party financing (CareCredit, for example), and major credit cards. A good option is to employ a written payment agreement that locks in payments on a credit card; there isn’t the likelihood of patients not performing their part of the bargain when the office controls the payment process in this way.

Having a written financial policy comes in handy when discussing payment with patients. In addition, making payment arrangements in a private place rather than the treatment room (before treatment begins) helps in forming a good understanding as to how payment is handled and tends to produce positive outcomes.

What happens if these methods are used and the account goes bad? For instance, a patient has treatment that was financially arranged, a co-payment is made by the patient, insurance is submitted and eventually pays a portion of the charges, and the end result may be an existing balance. (This may also happen in the case of a patient who has treatment, does not have dental insurance, and a balance is still due.) Now the fun part: The person who is the guarantor has lost their job, or a spouse isn’t working any longer, and money isn’t available to pay the existing balance.

Now what!?

Here are some steps to consider when managing this state of affairs. First, send a statement. Shortly thereafter, say a few days, call and talk directly to the guarantor (or patient, if one in the same). Indicate insurance has paid, and the balance is their responsibility. Be as gentle as possible; use soft yet direct language such as, “Can you make a payment of any sort?”

The important aspect of this step is to open a dialogue and try as best you can to get the patient on some sort of automatic debiting process on a major credit card. Mention to the person, “We can work with you by spreading your payments out over the next few months by debiting your credit card monthly”. If it is declined once, make contact and work with the person. If it is declined twice, then send the account to the agency, attorney, or company that will initiate collection proceedings.

Out of embarrassment, patients tend to ignore statements and phone calls. Using pre-collection letters on colored paper (bright pink, orange and yellow) has proven effective. Here’s an example of the first letter that sends a gentle reminder of payment.

Will you please give me a few minutes of your time?

Serving you, our patient, is our number one priority at {Practice Name}. We want to make sure that all of our patients are completely satisfied with our office. Since your account balance is now overdue, we wanted to contact you.

On the other hand, if you’ve simply overlooked paying this balance on your account, just send payment via personal check or major credit card. If you need help with payment, we will gladly work with you to make arrangements that meet your needs.

Thank you for your attention, we look forward to your call.

Follow up a few days later with a phone call to again attempt to form a dialogue with the patient.

The next letter may be nicknamed, “The Expedite Payment Letter”. This will use similar text as the first letter mentioned earlier, but must be a bit firmer. If after two weeks there is no response, send a firm collection letter, accompanied by a collection phone call. The message on an answering system may be something like, “This is a phone call to collect an unpaid debt.”

If after two more weeks there is no response, then send the account to collections.

It is also very important to have patients and guarantors become aware of any fees charged for past due balances and for any collection fees which are to be paid by the patient and/or guarantor. A disclaimer for payment of fees charged could read something like this:

I have read and understand the above financial policy for {Practice Name}. I also understand that I am responsible for all charges which my insurance company may or may not cover at the level anticipated.
Should collection procedures become necessary, I agree to pay all collection agency costs, (amount charged by collection agency), and/or reasonable attorney’s fees including late fees.

Put this in the written financial policy and/or in the financial arrangements section of the treatment plan produced by the office’s practice management software.

Be clear about how the office handles insurance; use something like:

We are happy to file the forms necessary to see that you receive the full benefits of your coverage; however we do not guarantee any estimated coverage. Because the insurance policy is an agreement between the patient and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy.

Have the financial policy signed up front, by the patient during their first visit. Include it as part of the patient file. Scan the document for the record, or include it in the chart.

Consider adding a missed appointment policy where you feel it would be beneficial to charge for missed appointments. An office can charge for missed appointments, but cannot collect on these charges as they are not a bad debt. The charges can be written off if uncollectable; however, if and when the patient returns, collect the fee at that time.

Another question that comes up is, “Can we send a patient to collections if they haven’t paid their full portion and the crown isn’t seated yet?” Or, better yet, “Do we have to seat the final restoration if they are unable to make a full payment?”

First and foremost, a dentist must finish that which he or she started – regardless of the ability the patient has to make full payment for services. This gives a lot of credence to having the patient pay in full at the preparation appointment rather than making arrangements such as asking for “½ at prep; ½ at seat”, or some other arrangement which runs the risk of having the office finish treatment without being paid in full.

If a patient has a balance due on an account, remind him or her of the amount owed when making the confirmation call. Politely inform the patient that the balance will be due when arriving for the next appointment:

“Just confirming your appointment for tomorrow. The balance due for your treatment is $300. Please bring a method of payment; we’ll see you then.”

Do not leave this on a messaging system; due to HIPAA regulations, your voice mail message should be something like:

“Hi, this is Vicki, I’m calling from Dr. Smith’s office regarding your dental appointment. Please call back as soon as possible; our phone number is 555-1212”.

Make sure the conversation regarding payment is made directly on the line with the patient/guarantor, or parent if the patient is a minor.

On the collection call, make sure you identify yourself and where you are calling from; that is, the name of the office or of the dentist. If you’re not speaking to the patient because the patient is a minor, confirm you are speaking with the parent or whoever signed to be responsible for payment of the account. Confirm with that person their name, date of birth, and their address.

Incidentally, there is some question as to who is responsible for a minor brought in for treatment. On occasion, mom will bring her child and complete the paperwork indicating dad is the responsible party. Not true. Dad may very well be the responsible party outside of the practice; however, the person who signs the financial policy at the time of admitting the patient to the practice is responsible for payment. As another example, grandma brings this same child to the dentist’s office, mom didn’t drive but signs the paperwork, and claims dad is responsible. In this case, mom signs the paperwork; mom’s responsible.

Managing payment during tough economic times can cause stress and frustration. Use these methods to ward off potential conflicts before they become serious problems and your office will run smoothly.

I’m looking for some help in how to let my team know what I expect of them and how I’d like them to participate in reducing stress in the workplace.

Wow, you have stress in the workplace? Welcome to the real world!

No matter how many employers a person has over their career, it’s inevitable he/she will have conflict; it’s human nature. Managing conflict in such a way that it creates an alliance, rather than an obstacle, is the result of successful management and people techniques.

At times, the education and experience of the worker and manager are different. Take a dental office, for example. The new employee may have had to “pull themselves up by the bootstraps” and has endured many obstacles in their personal and professional lives. This may have given them much experience in the school of hard knocks and they may have witnessed different management styles along the way; even though the employee may have no formal education after high school. On the other hand, a dentist who owns their own practice may not have pursued any formal business or people management training, and may have never learned the art of diplomacy. This connection with a new employee and dentist may result in frustration, anxiety, and stress.

Building a great relationship with people on both sides is key to good management and ever more important in today’s changing times. A sluggish economy has forced layoffs and other cutbacks in businesses of all sizes, resulting in high stress, low morale, and concerns about job security. People have fewer options in terms of walking away and keeping a job has more to do with balancing technical and interpersonal skills. During the late 1990’s, dentistry was experiencing wide spread growth and prosperity. In comparison, it’s more difficult to sustain growth and profit today.

When a small business such as a dental office relies on outstanding people performance, management and people skills go a long way towards weathering the storm. One must avoid loosing ones temper, being defensive and controlling emotions in general in order to be constructive in dealing with workplace conflict and performance.

A dentist who by default has become a manager of people must be able to get as much from his or her employee’s as possible; but no employee should be a doormat. Realistic expectations of job performance and behavior must be clarified up front. For example, an agreement to “go the extra mile” when a patient calls with an immediate concern and must be seen right away should be discussed. As a result, it is then understood that occasionally, the office must stay open and workers may have to stay late to tend to the needy patient. Agreed, it should not be the normal operating event.

Keeping the practice’s big picture in mind is vital, too. Dentists as managers must share with the team the vision of the office and have it become a component of day-to-day activities.

Flexibility with events and embracing change is important. Good employees, for example, will try to handle all they can and resolve those things that are causing patient service problems during the course of a busy day. Staying calm, thinking things through, and being fair will most often help everyone come to a sensible solution.

In answer to your original question, here are some down-to-earth approaches that dentists as managers can impart to their employees that will help resolve conflict and stress in the workplace. Perhaps this is a “cut-out” that can be the agenda topic for the next team meeting.

1. Understand what the dentist wants.
   1. Develop a knack for reading the dentist’s mind; pay attention to feedback and address any concerns immediately.
2. Keep the dentist in the loop
   1. They don’t like surprises and embarrassment. When things are going well, a short message or conversation, would suffice. When a problem arises, don’t hide it; explain and offer solutions.
3. Don’t waste his/her time.
   1. Write down what you need, be ready to answer questions, then leave if the reply isn’t appropriately forthcoming. Follow up with a reminder memo, if necessary at a later date.
4. Be a rock.
   1. Show up early, meet deadlines and volunteer for work when you have free time.
5. Don’t take criticism personally.
   1. Keep an open mind, control your emotions and always stand up for yourself, politely, but firmly.
6. Don’t play games.
   1. Never criticize or gossip about a co-worker, and mind your own business.
7. Know his/her quirks and accommodate them.
   1. Does he/she prefer notes, formal memos, or straight up communication – face-to-face?
8. Pitch ideas.
   1. Make sure they’re reasoned, solution-oriented and don’t add to the workload of others while somehow skipping yours.

Consider these successful management techniques as tools of the business. Work them into your practice and proactively ward off stress and conflict in your practice.

Saying Thank You Before the Thought Fades Away..

Several years ago, I recall a client of mine who was running a very profitable general dentistry practice and contacted me questioning his giving of annual bonus’ to his employees. He based the bonus on length of time served in the practice, overall productivity of the office, and pay scales of the employees. Through all the years he had been paying bonus checks, only two employees had ever said "thank you." Neither was still with the company. One moved to the east coast, and the other retired to a small town within the state where the doctor practices.

My client was so disappointed with this lack of etiquette that he discontinued the incentive bonus program, and if anyone had the guts to complain, he would quickly retort, "I have been paying bonus’ for several years, and no one has bothered to say thank you. When one of you takes the initiative and says thank you, I might consider bringing back a bonus program.”

I sat back and pondered this dilemma and what came to my mind were the gifts I would receive as a child from friends for my birthday or Christmas, and also gifts from my grandparents. It wasn’t the gifts that came to mind, per se, it was the lesson from my mom and dad to send thank you cards and acknowledge the gifts received. Besides, grandparents and others may have wondered, what happened? Was the gift lost in the mail? Did the poor thing lose the power of speech or the use of his writing hand?

I’m sure there are countless stories out there of people who have sent a birthday check and not heard a word back. Perhaps the only evidence that the gift was received is found among the pile of canceled checks returned from the bank! Oh well, the benefactor must think…”hope they bought something nice for herself.

On occasion, I’ll receive exceptional service in a restaurant and leave a larger than normal tip, hoping that the server would realize a larger tip is a sign that I enjoyed the experience and would like to return, particularly if my generosity is acknowledged. This hasn’t happened yet: the server hasn’t followed me out and said, “Hey, I just wanted to thank you for your generous tip, I really appreciate you showing how much you enjoyed my service this evening. When you return next time, ask for me, I look forward to seeing you again!” Right: what world am I living in?

If you're a dentist and have recently completed a large case that the patient either pre-paid, or paid in full, what have you done to make that patient know how you feel about it? It’s great to bank the money and have an above average month in collections because of the huge case you just completed, but what about the patient who received the treatment and is now part of your success story in dentistry?

A thank you just makes sense. A prompt thank you is easy to say, a lot easier to say than “Gosh Mrs. Jones, I neglected to tell you how much I appreciate you as a patient,” or “How've you been after all this time?”

In New York City, several years ago, the police are enforcing the quality-of-life laws and then Mayor Giulianni is even calling for the city’s cabdrivers and waiters to improve their manners, pointing out that rudeness is not a great civic selling point. It seems to be working. Crime is down. Tourism is up. And, the city is on a roll!

Many dental offices wait until the holidays to say thank you. A Thanksgiving card to patients is a common form of marketing this time of year. Nothing wrong with that, but why wait? Seize the moment, and be more responsive by saying the magic words the moment it’s appropriate. Stay away from the “corporate logo” stuff, those are fine for advertising, but it’s not a gift.

I try to tell my clients, day in and day out, the best gift a dentist can give to his or her patients or team members, have no monetary value. They are the hand written cards that say, “Thank you for being such a great patient. It’s people like you that make me proud to be a dentist.” Additionally, a telephone call on the evening of treatment to make sure patients are well is a tremendous way dentists can show how much they care about the well-being of their clientele; although not an outright “thank you”, but a powerful gesture nonetheless.

I recently received a note from a dentist client of mine saying, “Thanks, Fred. I couldn’t have done this (transitioned his practice) without you!” Needless to say, I was on cloud nine for days!

Imagine what would happen if you caught someone who works for you doing something exceptional and you say to him or her, “Thank you, I really appreciate you being here. You’re a fantastic team member in this office!” Believe me, an action of this sort will be extremely well received.

Sure, it’s a two way street. You’d like your employees to do the same when they are given a bonus or rewarded for exceptional performance. Part of leadership is doing those things you would hope your employees would do as well. Lead by example, then. Say “thank you” more often when the occasion presents itself; you’ll see it come back in many ways.

"I read your article last month on backing up data properly to guard against computer crashes and other events. Can you give me some more information on Online Backups?"

As it turns out, during an interview with a vendor of on-line backup services to prepare information on this article, the vendor related a story of a dentist who called late in the day prior to my discussion. The office manager was performing “Month End”, a regularly recommended accounting and practice management routine in Dentrix. By the way, Dentrix recommends the office perform a backup of the data prior to running this utility. After running Month End, the program reported an error and the dentist noted a significant loss of data, in particular, a large portion of the appointments, production information, accounting information, and claims was gone!

The dentist asked the vendor, “Did I perform that On-Line back-up we were talking about?” The vendor responded, “No, you have not subscribed to the On-Line version of our back-up services; all of your data is backed up on tape drives.” The vendor then recommended the dentist find out what tape was used for the most recent backup, place it in the tape drive, and together they will try to restore the data from that point. As it turns out, the tapes were not labeled, and the dentist and office manager spent considerable time trying to discover which tapes were used; unfortunately by trial and error! Once the correct tape was found, it took nearly seven hours to restore the data from the backup tape. Then, all of the information from practice operations over the previous 24 hours that was lost had to be reconstructed, primarily from memory, and then manually entered back into Dentrix.

OUCH!

Authors Note: Okay, so now all of you out there in dental land are going to pay attention and implement or confirm that a sensible and consistent backup routine is protecting the valuable data in your office! This event doesn’t even take into account something that would be out of one’s control, i.e., fire, theft, thunderstorm, electrical power surges, etc.

While we're on the subject, in the dental industry, Management Software failure and operator error are the common culprits in losing data. Hardware failure comes next, then conversion from a previous practice management software program to new management software contribute to data loss and or corruption.

In the past, dentists may have conducted full backups on tape as a daily routine. This was not recommended in the past and is not now. Here’s why: a corrupted file or program may kill important data and information; the daily full backup routine then wipes out all of the good data and replaces it with corrupted data. Without careful inspection each time a backup is performed, in this case daily, one would backup corrupted data until the error is discovered somewhere down the line. It begs the question, “How much data have I lost, and what do I do now?”

Over the years, technology has advanced to the point where there has been a logical progression for small and large businesses wanting a remote off site location to backup data. Online backups became noteworthy as early as 2005 as the capability to acquire faster and higher quality Internet speed, commonly knows as bandwidth, brought on the ability to upload and download data faster than usual. Additionally, storage mediums, as they exist today and existed only a few years ago, are a problem. Traditional backup systems were faulty in that a tape cartridge could fail, or if one were to drop an external hard drive, or HD, loaded with valuable data, it’s toast. Even if one takes perfect care of a backup device (tape or external HD), if one small element of the device becomes de-magnetized, the whole backup may fail.

Hardware companies also expanded their ability to produce products that will store huge amounts of data at a much lower cost; in some cases, a computer used by a company who provides on-line backup systems can store up to 30 terabytes of information. Just to clarify for you non-byte heads, one terabyte is equal to 1,000 gigabytes; and one gigabyte is 1,000 megabytes; and one megabyte is 1 million bytes of data. Okay, that’s a lot.

These events removed most of the barriers to entry for small businesses to utilize components, high-speed Internet and large storage devices, for remote backup services.

In the internal workings of a dental practice for example, data changes frequently – every minute of every working hour of every working day. And an office that has a database that changes frequently and wishes to back the data up regularly will encounter a bottleneck: bandwidth; in particular when uploading or sending files out of the system. More often than not, uploading files can be as much as 10% slower than downloads (bringing data in). This can pose a huge problem for dental office with large databases, some which may exceed 150 gigabytes (150 billion bytes of data), containing digital x-rays and digital images (pictures). If the connection/bandwidth is slow going out, it’ll seem to take forever and a day to backup online! My suggestion is to test the upload speed of the Internet service. Contact the Internet Service Provider (ISP) and ask them to test the connection speeds for uploading and downloading data. If it’s slow on either end, ask for a quote on upgrading and determine if it will be cost effective to upgrade or stay with the current configuration.

What was missing from the equation but is now available with high speed Internet and large storage devices is software that allows one server, the main computer in the business, to communicate with another server, a large storage computer off site. This type of application allows the customer to install software on the computer at the dentist’s office that collects data, images and all other information, and sends it over the Internet encrypted to a remote off site server, or computer, for storage. The data transferred would appear as folders with letters and numbers that cannot be deciphered by the online backup services company. This, of course, complies with HIPAA requirements to protect private information.

Where online backups can be useful is when documents of a much smaller size in Dentrix or QuickBooks, for example, can be backed up quickly and frequently. These include the appointment book, patient notes, the ledger, the QB data file, just to name a few.

Some software will also keep record of modified files in the history – keeping previous versions of files.

Timeliness is an essential element in backing up data. In most cases, one would have a removable HD system to handle large databases (i.e., x-rays, and digital images), with one cartridge for every day, removed off site each day in a rotation. Human error may enter into the event; the person responsible may forget to take the cartridge home, the backup may fail unbeknownst to them, or the employee leaves the same cartridge in day after day.
Redundancy, or concurrent backups, is a strategy where one configures the backup of critical data during down time (evenings) while the database isn’t being used, and then uploaded to an off site server. Further, the backup system of choice usually can be configured so that the system only backs up when the system is idle – in most cases, this occurs during the evening hours when the system isn’t being utilized.

Most backup systems can run concurrently. For example, an office could run a backup system using an external HD and set a window of 11 pm to start, and an online function to begin from 8 pm to 6 am; both won’t conflict with each other, and the backups will function together.

An opinion regarding online backups is that it would not be a suitable backup solution for extremely large databases (images, x-rays, etc.). Some advanced restorative dentists who collect many digital extra-oral images, digital x-rays, etc., create such large databases that the online backup systems may cause a problem when transmitting these large files of data. In addition, to retrieve a significantly large database in case of a crash, or to restore missing information, can be very slow and take a considerable amount of time. An alternative, and a significant advantage to online backups provided by some vendors, is after the first initial backup of all data on the client’s server, only additions, changes, deletions, and modifications may be backed up. This will save considerable time when conducting routine backups on a daily basis in that smaller amounts of data are transferred and backed up, rather than regularly backing up the entire database.

The vender of online backup services has a choice to put their servers used for online backup in Data Centers. These typically provide government rated security with key card and biometric entry, and lock and key cabinets for safeguarding the data. In other words, the only way to access the computer with the data stored from your dental office is for the person to have an electronic key card, a thumbprint of the vendor, and a key to open the lock on the cabinet where the computer is stationed. Pretty secure, I’d say.

Finally, what happens if “operator error”, a hardware crash, or other catastrophe falls upon the dental office? Using a reputable vendor will assist in retrieving your data in case something happens. One potential “fly in the ointment” is that downloading data from the remote source in an attempt to restore the data may take a considerable amount of time due to the large file size being transferred. Sure, this is one negative aspect of backing up information remotely. However, a good vendor will be able to retrieve the data and place it on a portable storage device and hand deliver it to the office and conduct the restore function on-site.

Pricing. Traditional backup services have been a “pay for amount service”; the more you backup, the more you pay. Recent innovations offer a much more reasonable solution, in terms of pricing, with no limits to the amount one can backup.

Reasonable industry rates seem to be in the neighborhood of $2 per gigabyte backed up. Fees can vary from $50 per year, to $25 per month up to $55 per month for larger databases with added services, such as recovering lost data by bringing the backup to the office and assisting with restoring.

Summary. The main advantages of online backup is there are no tapes to worry about, no worries about a CD or DVD being scratched or cracked, no external HD to worry about malfunctioning, or any storage device being left behind in the car during the sizzling hot summer months. And did I mention this earlier? Any backup function that involves people is open to human error; which happens to be the most common culprit.
A business, dental office is no exception, without proactive backup and recovery policies will face considerable hardship in lost business and revenue; and may face the risk of being out of business within a short period of time following a major computer disaster. Loss of business data may ruin a company’s reputation and/or may lead to expensive litigation as a result of not properly protecting important information.
Make sure the vendor who provides online backup services provides details of what is included. Ask if application data is being backed up, such as Dentrix, QuickBooks, MS Office, digital imaging applications (Dentrix Image, Dexis, Kodak, TigerView, etc.). Also, what kind of communication is sent back once a backup routine is performed; such as e-mail’s sent nightly to the customer, and messages if the backup failed or if a problem occurred. If data is lost at the dental office, will the company come to the office and assist with the restore process to be sure the business doesn’t lose valuable time, data, and money.

Databases are becoming larger every day. Data such as e-mail's, accounting entries, and patient appointments, change daily. One can never have too many redundancies in backup up critical data. Hiring a competent computer technician is a good idea to help with the Information Technology aspect of a dental practice. Be Proactive, and don't get caught with a computer crash or human error causing a problem where a good backup routine was missing or inefficient.