Maximizing Treatment Plan Case Acceptance

As certain of these questions are being asked, it is important to empathize with the patient’s answers. This is an opportunity to let the patient know that the things that concern them will be taken care of in this practice. Every statement the patient makes should be met with an empathic understanding. If the patient states that they have not visited a dentist in, say 10 years, the advocate must let the patient know that it is okay, as in “We have a lot of folks in the same category, and they end up relieved and pleasantly surprised by how easy we make their visits.” If the patient states they don’t have a lot of money, the advocate states the same basic answer. The goals are the same: put the patient at ease and remove the psychological barriers that prevent them from coming to a dentist.

The advocate must cultivate a sincere kindness in their telephone demeanor. They must treat the new patient caller as if they are an old family friend they have not heard from in years. People respond to warmth, kindness, patience, and understanding. Those are the effects the advocate must have on the patient.

There are a series of questions that are asked the patient, beginning with the new patient telephone call. The questions are designed to tell the advocate—and entire practice—how to best approach, listen to, talk to, and direct the patient.

Besides the contact information and insurance information, there are a few other questions that need to be answered by the patient during the new patient telephone call. Among them are:

How did you hear about our office? Get specifics, so if you have a certain marketing special offer available, you’ll know which offer the patient is calling about.

“Is there anything in particular you would like us to look at when you come in?”

“May we ask when your last dental visit was?”

“Do you have access to your last x-rays?”

If they left another practice, ask, “Is there any particular reason you decided not to go back to your last dentist?” This answer will tell you the items to be on the lookout for. Make sure they are communicated to the entire team at the morning huddle.

For new patients we also let them know what our Standard of Care is for a new patient’s first visit. Dialogue would be as follows:

“Mr. Jones, your first visit to our practice is really important. We want to make sure you receive the best care in the most comfortable manner. So the doctor will perform thorough examination, a complete set of x-rays, a soft tissue and periodontal screening and an oral cancer check. We cannot perform a ‘teeth cleaning’ on your first visit because we don’t know what type of cleaning you will need: there are several ways to proceed with cleanings. They all are different in time needed. And sometimes other clinical issues determine the type of cleaning. This process ensures the highest Standard of Care for you.”

By the answers to the above questions, we know the “hot buttons” of the patient: why they left the last practice, why they have not been in for a while, what their concerns are, how they will finance their treatment, and what they are looking for in an office.

The advocate begins to build a full understanding of the patient’s history, and will address any concern with a re-assuring statement about how this practice will perform the way the patient desires. The goal is to make the patient feel like they will love the dentist, the practice, and have a very positive experience.

The Advocate ensures the new patient has all the information they need before the first visit. They let the entire staff know in the daily huddle (to be covered in the coming Organizational Structure Section, Daily Huddle chapter), the salient concerns and issues of this new patient, so everyone can reinforce positive information.

The Advocate’s Role in the New Patient Intake Interview

At the patient’s first visit, the Advocate greets the patient by name, introduces herself or himself and their role of Patient Advocate:“I will be your Patient Advocate, Mrs. Smith, a title Dr. Smith gave me. It means my job is to make sure you have the best experience in a dental practice you ever had.”

The Patient Advocate tells them how we have been looking forward to meeting them. The Advocate must communicate sincere warmth and empathy. Use personal inquiries and ice breakers such as, “How was the drive in?” and “Did you find the office ok?”

The patient’s health history and other patient information is completed, including insurance verification. The Advocate will escort the patient to the consultation room, or a private area, and let the patient know you are going to go over today’s visit so there are no surprises. This is the Intake Interview.

At the Intake Interview, the Advocate will review paperwork, go over who we are in the office, find out a little more about the patient, and really have the advocate bond even further with the patient. Empathize with the patient by telling them we understand that a dental visit may not be the first place they want to be, but our practice goal is to change that perception by really giving our patients everything they want, need and prefer. The advocate’s job is to do just that.

The Advocate will then ask the patient why they are here today, and what do they want, or prefer. Review the reasons the patient left their last dentist, and what the reasons were for leaving. Reassure the patient those factors will not happen at this practice. Tell them your job is to prevent that from occurring.

Also, use this opportunity to educate the patient about their insurance, and dental insurance in general. Whatever type they have, we let them know it’s a good benefit and will help them save substantially from the UCR (cash) fee. We want to make sure they understand dental insurance is not really insurance in the traditional sense. It is a benefit their employer purchased to help them save from the UCR fee. No insurance pays for every dental procedure. But let the patient know they should not worry about the dental fees, because you, the Advocate, will make any treatment they might need affordable.

The Advocate must address the three major reasons patients don’t like dental visits, and remove them. The first is the fees. If the patient is seeing dollar signs as the dentist speaks, they are not really listening to the dentist. They miss 90% of what is being stated. Concerns about costs need to be removed. Tell the patient to concentrate on the clinical information the dentist is talking about. Secondly, the Advocate must remove the pain aspect. Tell the patient the doctor is really gentle. Tell them all the patients tell us that. Tell the patient they are in control of the clinical process; all they have to do is signal and the doctor will stop.

The last big item to remove is time. We need the patient to understand their visit is a process, especially the new patient’s first exam appointment. They may want to rush in and get a quick cleaning, but they need to remember how much time they will be there. They need to hear why the first exam visit is the most important visit they will have. If the patient needs to use the phone, have a drink of water, use the restroom, etc., then get that out of the way. Remove anything that could be an obstacle to the patient being “present.” Good advocates use patient’s needs, fears, wants, desires, and paint the picture the patient wants to see. Here is the best line of questioning for the patient in the intake interview:

“Mr. Jones, no one may have asked you this before, but what are the goals for your dental health?”

At this point, the patient may offer up one of the many standard answers heard everywhere. These standard answers are universal, and we know ahead of time what they are. But it is critical that we get the patient to verbalize them. We make a big deal of paraphrasing their answers, and writing them down. We tell the patient that we—our office—will do everything to achieve those goals. The typical answers are “I want to keep my teeth for my lifetime, I want my teeth to look nice and feel good, I don’t want to have pain or emergencies, I don’t want to spend a lot of money and time at the dental office, I don’t want to come back over and over and be nickel and dimed, I don’t want to be kept waiting.”

Some patients seem dumbfounded when asked the goals for their dental health. After waiting for them a bit, our Advocate offers up some of our typical answers that we just listed above, to see which ones resonate with the patient. Again, we paraphrase, look for clarification from the patient, and write them down with our statement that we will use these goals as our guide throughout their visits with us.

You will constantly refer back to the answers the patient has given you in the intake interview all throughout the rest of the patients tenure in your office. You will see their will be nothing we propose to the patient that does not satisfy one or more of their stated objectives. We will detail those conversations in the forthcoming chapter Overcoming Patient Objections. There will also be further information forthcoming that demonstrates how to overcome patient objections.

The next step in the new patient visit is for the Advocate to introduce the assistant by name, and explain to the patient what the assistant will perform next.

The assistant will engage in some friendly discussion with the patient. They will lead the patient to the operatory and seat them. The assistant informs the patient which x-rays will be taken, that there is no pain from it, and if the patient brings it up, informs the patient about new, low-level radiation that is safer than most TV’s.

The assistant should make any mental and written notes about any comments and questions the patient makes. These need to be conveyed to the Advocate as soon as possible. As the assistant is taking the films, the assistant is encouraged to verbalize conditions that they see in a neutral manner. Questions such as “how long have you had those fillings?” or “does that molar bother you at all?” are non-judgmental questions that are allowable, and encouraged. Here is a full Assistant/X-ray technician checklist for handling the new patient:

Greet patient with a smile, introduce self and tell your credentials. Use Mr. or Mrs. when addressing an adult patient.
Be positive, reassuring, and speak to the patient with eye contact.
Let the patient know what films you will be taking, how safe modern films are, and what they will show the dentist and patient.
As films are developing, the intra oral camera is often used to explore the mouth. While the assistant cannot diagnose, they can point out and “freeze frame” any extraordinary things they see while using the camera. State “Let’s have Dr. Smith look at this crack. Have you had any sensitivity in this area?” Record the patient’s answers and comment as you navigate the mouth.

The Mini-Huddle Between Dentist and Advocate

As the assistant is taking films, the Advocate is with the Dentist reviewing the information the Advocate has learned so far about the new patient. This is the Dentist-Advocate “mini-huddle.” Together, they are looking at the x-rays, with both asking what any abnormal feature on the films might be.The Dentist will want the Advocate to be asking questions, such as, “Dr. what is that dark spot on that molar?” The Dentist must welcome these prompts, and see them as a whole team effort to point out any and everything that could be discussed. Remember, Informed Consent is the law, and states you must discuss any and all conditions with the patient. Besides, it broadens the treatment plan. Together, Advocate and Dentist have a mini “game plan” with which to address the patient: matching potential clinical needs with the patient’s emotional agenda.

Assistant and advocate will have their own mini-huddle where the assistant is relating any comments the patient might have said during the x-ray and intra-oral process. This may be together in the operatory so the patient can hear the discussion. This ensures accuracy of information, and allows the patient to comment again on their situation.

Next, the Advocate will re-enter the operatory and introduce the Dentist. The Advocate will summarize the main issues the patient has already told the Advocate out loud so the patient, Dentist and Advocate all hear the same items. The Advocate asks the patient if they have left anything out. Patients usually start talking more as the visit progresses, so you want to keep asking them for input.

The Advocates Role During the Clinical Exam and The Dentist Clinical Exam

The Advocate and the Dentist will diagnose, discuss, inform, prioritize, answer questions and concerns as a team. Therefore, their roles are tightly interwoven, and will be shown here. Again, the team concept recognizes that patient’s make decisions largely on emotion. Our goal is to “marry” the clinical needs with the patient’s emotional agenda. This results in the greatest case acceptance. Failure to recognize and address the emotional agenda is the greatest factor in case denial.

Introduction of “Big Picture” Diagnosing

More than looking for things to fix, begin to look at enhancing the quality of life for the patient.

As in previous Sections of Dentistry Simplified, we have included a quick survey questionnaire which may provide you with a guide, or a sounding board, as to what degree you are conducting your diagnostic sequence.

The Clinical Diagnosis Survey

1) Do you spend more than 15 minutes of actual chair time during a full examination?
? Almost Always ? Sometimes ? Rarely

2) Do you check the patient’s bite registration during every full examination?
? Almost Always ? Sometimes ? Rarely

3) Is your average treatment plan (total of diagnosed tx, not necessarily what is presented) more than $1,000?
? Almost Always ? Sometimes ? Rarely

4) Do you take study models during the full examination?
? Almost Always ? Sometimes ? Rarely

5) Do you conduct a full examination on all recall patients every two or three years?
? Almost Always ? Sometimes ? Rarely

6) Are you commenting on every tooth you see during the full exam?
? Almost Always ? Sometimes ? Rarely

7) Are you looking just to “fix things” in the patient’s mouth, and not including all /any enhancements for the patient’s overall health and well-being?
? Almost Always ? Sometimes ? Rarely

8) Do you give the patient at lease one additional option for treatment during the full examination?
? Almost Always ? Sometimes ? Rarely

9) Are you and/or your patient advocate using intra-oral photos or camera during the full examination?
? Almost Always ? Sometimes ? Rarely

10) Are you addressing the patient’s chief complaint clearly, and tying it in with other treatment conditions you see?
? Almost Always ? Sometimes ? Rarely

11) Have you and/or your patient advocate stated “why” certain treatment is being discusses, as well as what could possibly result if no treatment is begun?
? Almost Always ? Sometimes ? Rarely

12) Are you listening and looking for “cues” from your patient advocate regarding points of concern/objection by the patient?
? Almost Always ? Sometimes ? Rarely

Download the Clinical Diagnosis Survey | Get Acrobat Reader

The Basic Approach to Diagnosis

Diagnosis can be broken down into 4 basic categories:

1) Immediate need items: broken tooth, root canal, stop decay, restorations to prevent further damage, etc.

2) Preventive: all types of cleaning, periodontal prevention, mouthguards, all diagnostic procedures, medicaments, etc.

3) Cosmetic: restorations for color aesthetics, veneers, teeth whitenings, treatment based on aesthetic wants, etc.

4) Orthodontic: straightening of teeth for aesthetics, occlusion oriented orthodontics, etc. Malocclusion affects 74% of American adults. Poorly aligned teeth can create unnatural stress and pressure on teeth and jaws. Some dentists see 3 out of 4 orthodontic cases in adults originate from a malocclusion condition.

As you recall from Section “Standards of Care,” code 0150—Thorough and Complete Examination—applies to patients who are either new patients or patients who have been absent from the practice for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues.

Some of the commonly missed issues to address during examination and diagnosis are crowding of teeth, cross bite, open bite, spaces between teeth, and diastema. Include an evaluation of the patient’s smile: there may be some irregularity as simple as a single tooth that is protruded, rotated, or misshapen. Many times, these things may have bothered patients for years, but they have not been given an option to enhance them. Make any and all irregularities known to the patient. Remember, Informed Consent is the law. You must at least inform the patient of all conditions you see, even if you do not treatment plan it.

As we should be looking for things not just to fix, but to enhance the patients life, the diagnosis and evaluation may require the interpretation of information acquired through additional diagnostic procedures than are listed in the standard of care code section referred to above.

Those may include:

1) Panorex films: Taken to view the bone structure of the jaw and of all the teeth including the surrounding tissues. This could give evidence of any existing abnormalities not shown in the FMX. This is often needed for orthodontics and oral surgery cases.

2) FMX: Although we already included this in the Standard of Care section, we will review it for another use: not only to diagnose, but for verification of needed treatment. It is required when billing insurance companies for any periodontal treatment as well as bridges. Insurance companies are wanting to see Arch Inegrity before reimbursing.

3) Oral/facial photos: These are used for identification, especially facial shots. These photos will show evidence of calculus, swollen tissue, cracked teeth, fractured teeth, decay, open margins, receeding gums, crowding (especially lower anteriors).

4) Diagnostic Casts: Taking these as Study Models is a real modeling method to evaluate the Bite. This can be used as a “time out,” so the diagnosing doctor can compare potential outcome scenarios of the case without the patient right in front of him or her. It allows the time for the dentist to ask themselves if they can “really make the patient happy with the outcome.” And, “do I really want to proceed with the case?” It also shows the dentist, and the patient the different options.

All of these diagnostic tools help to both increase case acceptance by showing hard evidence of the problems to the patient, and increase insurance acceptance and payment for the patient, by documenting the same hard evidence.

Taking these easy additional steps can prevent patients from walking away from treatment, and head-off insurance company problems. And can insure your reimbursement from the insurance companies. This is a good example of “an ounce of prevention is worth a pound of cure.”

Stage Two: The Advocate and the Dentist With the Patient in the Operatory

After the mini-huddle, the Advocate and Dentist will enter the operatory. The Advocate introduces the patient to the Dentist. The Advocate gives a summary of what the patient and Advocate have discussed up to this point: reason for being here today, reason for leaving last dental office, what the patient wants from a dental practice, etc. The Advocate then asks the patient if any information was missed or if there is anything else the patient would like to bring up at this time.

The Dentist will make a little small talk with the patient, exuding kindness, attentiveness, and confidence. The Advocate has conveyed the attributes of the dentist to the patient up to this point. Now, the Dentist must exhibit the qualities the Advocate has stated: empathy, understanding, patience, warmth, attentiveness, etc. The Dentist will review the Health History Form with the patient and Advocate. When there is a comfortable pause, the Dentist will ask the patient if it is ok to lean them back in the chair so we can see better. Asking the patient’ permission to proceed is important: it demonstrates to the patient they are in control, and we are listening and responding to them. Also tell them how they can stop treatment at any time they like, and how to signal the Dentist. Remember, most patients are a little apprehensive at this point. Let them feel secure.

At this time, the intra-oral camera is brought up to assist in the exam. Some dentists wait until after their visual exam to use the camera. Either or both work successfully.

Our goal for the Dentist during the diagnostic exam is to be fully inclusive. Remember, Informed Consent is the law. That means the Dentist is obligated to remark, advise, etc. on any possible dentally related issue in the patient’s mouth.

The Advocate or Dentist should tell the patient why Informed Consent is in the patient’s best interest. And, it actually gives the Dentist a legally based doctrine to be all inclusive in diagnosis.

This can, and usually does, result in expanded treatment planning. But also let the patient know not everything they hear is a problem. Approach the exam as if you are in a study club and have been asked to remark on any and every possible condition in the patient’s mouth. Do not be concerned with patient comments, insurance coverage, time, or expense. You are not proposing that the patient deal with everything you note. It will be later that you and the Advocate prioritize, sequence, and present the initial phases of what you may discover in the exam (the Advocate actually states that last sentence verbally to the patient as well).

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