AADOM Clinical Corner
Featuring Ann-Marie DePalma, CDA, RDH, MEd, FADIA , FAADH
At AADOM we recognize that as the business professional who manages the practice, you need to understand all facets of the business. There will be times when the business and clinical sides of dentistry cross over. The business team needs to have an understanding of clinical team responsibilities and vice versa. We started the AADOM Clinical corner as a resource for the management team to ask questions regarding the clinical team/area of the practice. We’ve enlisted the assistance of Ann-Marie DePalma, a dental professional with over 25 years experience in clinical hygiene and a background in dental business consulting.
How Should an Effective Hand-Off be Handled Between the Clinical and Business Team?
The hand-off from the clinical team member to the business team member is an important communication skill that provides the patient with the assurance that the team members know what their needs are and are confident in the treatment provided or needed. When clinical team members merely bring the patient to the business team and “drop off”, the business team and the patient are often wondering what was done that day and/or what needs to be scheduled next visit. Whether the practice uses the practice management software for communication or provides paper or other communication tool, the hand-off from clinical to business needs to be seamless. Often there is the communication between doctor and hygienist or assistant in the operatory, but sometimes that doesn’t get transmitted to the business team. If the communication between doctor, hygienist/assistant and patient has not been initiated in the operatory, the hygienist/assistant can begin the process by recapping for the patient the day’s treatment and the next visit needs before bringing the patient to the business office.
Initiate the hand-off process by bringing the patient to a seated position in the operatory chair and maintaining eye contact, the hygienist/assistant can recap the day’s treatment and discuss future appointments. The importance of the day’s visit and future treatment can be stressed to the patient at this point, which helps build value for the patient for future dental care. Once that is completed and any questions asked and answered, the hygienist/assistant can bring the patient to the business office and reiterate the completed treatment and future treatment for the business team.
The business team member should already be aware of the information since the clinical team should have communicated the information prior to bringing the patient to the business office. The repetition is done for the patient’s benefit – the more times an adult hears a message, the more they understand and will take action. Additionally, the clinical team should position her/himself between the patient and the door to signal to the patient that it is not time to leave yet, while also shielding from other patients in the reception area.
Following HIPAA guidelines, especially if other patients or team members are within hearing, the exact treatment completed or planned should not be stated, but generalizations used. If appropriate, the clinical team member can give the patient her/his business card for any further questions or information (as well as to build potential referrals) and then the business team member can finalize the day’s appointment or handle scheduling future appointments.
If the patient does not wish to schedule future appointments at that time, the business team member should ask the patient for permission to make a follow-up contact if they have not heard back from them in a specific time frame. Often “life gets in the way” and well-meaning patients often forget to contact the office to schedule treatment. All of this does take a few extra minutes during the appointment, but since repetition is the key to learning, the patient’s current care and future needs will be reinforced, thus building value and respect for the practice and their individual treatment needs.
This triangle of patient, clinical team and business team communication may need to be practiced – spending time at team meetings to review the process may be effective. While business team members are not only responsible for checking out patients, there are a multitude of other responsibilities that exist. By planning and practicing an effective hand-off, all team members begin to understand how their actions, or lack thereof, can affect others abilities to do their job well and improve patient case acceptance.
How Do I Handle a Clinical Team That Isn't Completing Their Duties - Chart Notes, Treatment Planning, Etc.
When team members don’t “pull their weight”, resentment builds within the practice. The old adage, “there is no I in team” is so true when dealing with team members who refuse to complete assigned duties. Often when these same team members are asked about their job roles and responsibilities they don’t know how to respond. Many times clearly defined job descriptions are lacking. Does your practice maintain a job description for every employee? Are these discussed annually and changed appropriately?
Once clearly defined roles and responsibilities are outlined and discussed, the team members need to be held accountable for actions or non-actions based on their role. If a hygienist, assistant or business team member is assigned a task and the task has been clearly defined yet the hygienist, assistant or business team member does not follow through with task, she/he needs to be held accountable for their lack of action. Whether the owner/doctor or office manager is the person holding the accountability, team members need to understand the consequences of not performing according to their position.
All team members need to be held to the same standards; when some are “getting away” with not performing appropriately, other team members feel that they can get away with similar actions and tensions can build within the practice. Tension can then be felt by not only the team, but by patients. When patient care is placed in jeopardy by tension or inaction, the entire team and practice suffers. Holding team members accountable for actions based on clearly defined roles and responsibilities can be difficult, yet holding these discussions and holding the team accountable is a sign of a good leader.
Who Should be Discussing Financial Information with Patient, Including Insurance Benefits?
Each team member is an expert in her/his area of the practice; whether a business or clinical team member each person specializes in their knowledge and skills that benefit the practice. When a team member discusses an area that another in the practice is an expert on, it can create confusion in the patient’s mind. Confusion creates paralysis – the patient may or may not proceed with recommendations.
Clinical team members whether hygienists, assistants or doctors are the experts in the practice regarding patient treatments and conditions, not the insurance and financial aspects of the care the practice provides. Business team members understand the complexities of the financial world of dentistry whether involving patient investments or insurance benefits. When the clinical team ventures into an area that they are unfamiliar, inaccurate or inappropriate information can be presented to the patient. The clinical team may have knowledge of the patient’s insurance and while practice management software programs allow the clinical team to review insurance basics with the patient, the intricacies of patient finances need to be devoted to the team member who understands those intricacies.
Whether a small or large practice, a business team of 1 person or 20 people, the details of finances need to be handled by the expert of the practice in finances. Additionally, clinical team members are required to provide the patient with the appropriate treatment at the time. Insurance benefit plans require the treatment to be documented by the appropriate treatment code. Clinical team members are not experts in the codes, that is an area for the business team, yet the business team doesn’t know the treatment provided. Practice revenue is based on the treatment provided and the code that is used – teams need to understand these requirements to use the appropriate code for the treatment provided. Anything less can cause issues. When clinical team members venture into discussing that a code or service can be billed if it wasn’t appropriately used, ethical, legal and moral issues can arise. It is the practice manager’s responsibility to ensure the appropriate discussion is provided. These discussions can be either one on one conversations with the clinical team member or a team meeting to discuss the practice philosophy regarding handling the treatment investments for the patient and use of the appropriate code. These can be difficult discussions but in order to be a high performing efficient practice, each team member needs to understand the role their words and communication can have on the practice.
Being “insurance aware, not insurance driven” focuses on the importance of understanding the patients’ insurance but not being driven to provide treatment that only is “what the insurance will cover” rather than the treatment the patient needs. Team members need to understand that concept and the practice manager is the person to best convey that message.
How Can I Learn More About Treatment Planning and Products the Clinical Team Uses in the Operatory?
First, does the practice hold regular team meetings, including morning huddles and scheduled monthly, quarterly and annual meetings? Who runs these meetings? If the practice manager always organizes and runs the meetings, the team can be missing an opportunity to learn about various services, procedures or products. When team members are offered the opportunity to educate other team members, all members grow in their knowledge and understanding of each other’s roles and processes. Other than AADOM, dental managers and other business team members often don’t have opportunities to learn about clinical information while assistants, hygienists, and doctors are required to maintain continuing education depending on state requirements. During continuing education programs clinical team members often learn about new products. Having the ability to present the information learned at these programs back to the rest of the team during team meetings enhances the entire team’s knowledge and understanding.
With treatment planning, have you asked a clinical team member to explain a procedure to you or why it was recommended? A few years ago, an advertisement lauded potential buyers to “just ask about xxx.” Clinical team members enjoy when others ask for their opinion or to explain procedures or products. Everyone likes to feel valued and appreciated and asking a team member about a certain treatment or product in a non-judgmental manner can enhance the relationship. The key is to be non-judgmental since the clinical team member may consider it to be questioning her/his clinical expertise. Also, during team meetings time can be devoted to learning about a procedure to enhance everyone’s knowledge of the “why” behind a treatment.
The hygiene team in the practice would like the business team to use the D4346 code for patients. We have tried to use it several times but insurance doesn’t cover it. What should we do?
The hygiene team is correct given what the patient presents with on the day of service.
If the patient has symptoms of periodontal disease, with or without bone loss, the clinical team needs to document what the patient has and the appropriate treatment. When there is bone loss, D4341, D4342 or D4910 are the appropriate codes. If the team uses these codes the clinical notations need to document the reason for the treatment. If there is no bone loss but inflammation, D4346 may be used. With that said however, the ADA code D4346 reads: scaling in the presence of moderate or severe gingival inflammation – full mouth, after oral evaluation. This means that the treating dentist should do an evaluation prior to the use of the code and that there must be 30% or greater of sites of inflammation in the patient’s mouth. Inflammation means bleeding points. When periodontal probing is done the clinical team should be marking not only probing depth but bleeding, suppuration (pus), gingival margin (recession), clinical attachment loss, mobility and furcation. All of this information constitutes a full mouth periodontal charting, not just marking probing depths. Practice management software should be able to assist the clinical team in determining the percentage of inflammation. If the clinical team is using a paper periodontal chart, the percent of inflammation can be determined manually. If there is greater than 30% of inflammation, complete periodontal charting, intra-oral photographic images and radiographs showing no bone loss can be sent to the insurance benefit company. There is no guarantee however that it will be a covered benefit. Some benefit plans cover completely or cover at the periodontal (50 – 80%) rate, some downgrade to prophylaxis subject to prophy limitations, others provide no coverage at all. Dental practices are not responsible for determining whether a patient has coverage or not for a particular procedure. It is the practice’s responsibility to document what was done and the medical necessity of the treatment. As dentistry moves towards the medical model of care, medical necessity will become more important in documentation. Documenting that there is inflammation present with appropriate treatment notes and images can assist in maintaining that responsibility. Additionally with the advent of the new AAP (American Academy of Periodontology) staging and grading of periodontal diseases there is more information that can be documented. Clinical team members need to document what was done and the reason for the treatment. Many practices are reluctant to use the D4346 code since “insurance won’t cover it” and therefore they are not following the appropriate ADA guidelines. A number of years ago a new ADA code was introduced. The first year some practices didn’t use the code for fear of upsetting patients because insurance didn’t cover it, yet many other practices did submit the code. Due to the fact that many practices did submit the code since they coded what was done appropriately, the following year insurance companies began to pay for the service. If it isn’t submitted, it won’t ever become a benefit. Yet this involves educating the patient about their disease process and practices providing the clinical team with the time and tools to educate. Inflammation/bleeding is considered periodontal disease that is reversible – bone loss may not be reversible. Treating the disease the patient presents with is the ethical and legal responsibility of the clinical team and submitting the appropriate information to the benefit provider or billing the patient is the responsibility of the business team. Both must work together to provide the most accurate documentation.
The clinical team does not understand when and why we need x-rays and the importance of clinical notes.
As business team members, you may or may not have the skills and knowledge to read x-rays (radiographs). Yet, the nature of the business team’s work is such that the business team member needs to know which x-ray to send to a referring practice or to an insurance benefit provider. Because the clinical team member can see or feel the decay, doesn’t necessarily mean that the business team member can process the claim or forward an image to a referring office. Appropriate documentation and information must be included in both the clinical chart notes and the imaging software. Imaging software should allow for noting the clinical information, therefore the clinical team can denote the appropriate tooth number and possible diagnosis for ease of documentation. Yes, it may take an extra click or two to denote the correct information, but one of the clinical team’s responsibilities is to record the appropriate treatment. The clinical chart notes, images, billing and scheduling all need to be consistent and all team members play a role in the documentation process. If there ever was a review or audit regarding treatment rendered, the images and clinical notes would be held in question. It is not the business team who sees the patient, renders treatment or diagnosis, but the clinical team. The clinical team members are held to a level of professional standard of care. The standard of care is defined as the level and type of care that a reasonably competent and skilled health care professional with a similar educational background would provide under the circumstances. The standard of care for documentation usually mentions the appropriate notation of treatment rendered and diagnosis in a SOAP formula – Subjective, Objective, Assessment and Plan. All team members should be documenting any diagnosis, treatments, correspondence, patient compliance or non-compliance and conversations in a clear and accurate manner shortly after any interactions with the patient, family member/caregiver or other health care provider in order to protect the team member, practice and the patient.
The Clinical Team and doctors are asking the business team to participate in both OSHA and HIPAA trainings, do we need to do this?
I work in a moderate sized general practice where I am the practice manager with 3 other business team members. The clinical team and doctors (2) are asking the business team to participate in both OSHA and HIPAA trainings in addition to our regularly scheduled monthly team meetings. One of my business team feels that although she understands we need to be involved as a team, doesn’t feel that the added meeting is important for the business team to attend. How can I convince her otherwise?
First, is this team member new to the practice or has she been involved in previous trainings? If new, she may not understand the importance of OSHA and HIPAA trainings to the practice and the team. She may have come from a practice that had lax standards and she hadn’t been involved. It will be your job to educate her on why the meetings are important. If she has been involved previously, is it because she feels that the meetings are a “waste of time” with minimal changes in material and the way the practice handles OSHA and HIPAA? Either way, there are a variety of rules or regulations surrounding OSHA and HIPAA that require employers to provide annual training for all employees. These rules and regulations can be enforced by local, state or national authorities depending a variety of factors. There are many different types of options for handling these trainings from online, to in-office team member led, to in-office educator or sales rep led programs. Each has a different outcome and feel to the participants. As a hygienist I have spent many hours participating in both OSHA and HIPAA programs that have been both good and bad. Yes, the material doesn’t necessarily change that much (unless there has been some major upgrade to the information), so teams often hear the same information year after year. But repetition is one of the keys to learning. Hearing information more than once, whether it is in an educational program or the patient hearing about a recommended treatment, reinforces the importance of that information. I often have participated in events where the information was the same, but I “heard” it differently each time. If you have used the same type of learning material (online or in-office led) consider switching learning venues – if online, having an in-office training or vice versa or using a different educational source. If the source isn’t the problem, has the practice instituted procedures following previous trainings to ensure compliance? In today’s hectic dental practices, teams often embark on a variety of training programs, but fall short when it comes to actual implementation. Often either no time is allowed to change systems and procedures, or no one is held accountable for implementing the new information. Has this happened in the practice where training occurs but nothing changes? Is she expressing frustration because of this? Or does it have nothing to do with the actual OSHA/HIPAA but rather the doctors wanting an additional meeting? Having an open discussion with her without blame (using “I” messaging and conflict management skills) and asking her opinion for making the training better will provide insight into how she is feeling and why. In fact, she may express an opinion that other team members feel but are not willing to express. While OSHA is designed to protect the employees and HIPAA protects patients’ information, everyone on the team needs to be aware of the implications of participating and implementing protocols to ensure practice specific compliance.
When a hygiene patient is late, the hygiene team does not want to see the patient, while the business team says they should. This creates conflict and disagreement; is there a better way?
When a hygiene patient is late, the hygiene team does not want to see the patient, while the business team says they should. This creates conflict and disagreement; is there a better way?
According to the American Dental Hygienists’ Association standard of care, the hygienist is responsible for a variety of processes during the clinical dental hygiene appointment. Many hygienists feel time crunched to achieve all that needs to be done to maintain both the standard of care and the practice’s philosophy of care. A previous Insight Clinical Corner column discussed the importance of doing a procedure analysis to help identify areas that are time critical. Yet even with a procedure analysis the hygienist can feel that seeing a late patient encroaches on the time needed for successful treatment, as well as possibly making the next patient wait. Everyone’s time is valuable in today’s world so having someone wait when they are on time can often indicate lack of concern. Does the practice have a late policy and does the hygiene team understand the policy? If there is not a policy, it may be a good discussion to have at an upcoming team meeting. There are a variety of options when deciding on a late patient policy. If a patient is 5 -10 minutes late, the hygienist can see the patient for the full treatment. If longer than 10 minutes, the hygienist can have the option of either completing the full treatment or as appropriate, doing a portion of the treatment and then rescheduling for the rest of the treatment. For example, if a patient was scheduled to have imaging, prophy and evaluation, the hygienist and doctor can decide if the imaging can wait till next appointment and plan accordingly. Or the same patient can only have the imaging done and reschedule the prophy and evaluation, again with hygienist and doctor input. Most patients want to be on time, but often unforeseen circumstances can disrupt plans. The practice wants to provide care and offering the patient at least some of the schedule services provides a win-win for everyone. If the lateness is a one-time event, the hygiene team can determine the appropriate response based on the discussed practice policy. The policy should have input from all team members, in that manner, everyone has a stake in its outcome and has shaped the policy, thus be more willing to follow it. If however, the patient is chronically late, that is a discussion that you as the office manager and/or the doctor need to have with the patient as to how she/he can receive the treatment they need while providing the practice with adequate notice. It is always a good practice to have the hygiene team contact the patient after 5 minutes of the scheduled appointment time to ask if the person is ok and if they are on the way. This reinforces that the practice is concerned about the patient and is worried that something had happened. This concern gives the patient reassurance that the team is concerned about her/him and not just a number to the team.
Ann-Marie DePalma, CDA, RDH, MEd, FADIA, FAADH is a graduate of the Forsyth School for Dental Hygienists, Northeastern University and the University of Massachusetts Boston. Ann-Marie is a Fellow and Certified Educator of the Association of Dental Implant Auxiliaries (ADIA), a Fellow of the American Academy of Dental Hygiene (AADH), a continuous member of American Dental Hygienists’ Association (ADHA), as well as a member of American Association of Dental Office Managers (AADOM). She is the 2017 Esther Wilkins Distinguished Alumni of Forsyth Award recipient. Ann-Marie spent 25+ years in clinical hygiene, has experience in dental hygiene and assisting education and as a business/clinical consultant. She currently is employed as a technology advisor/trainer. In addition, Ann-Marie is a published author with dental hygiene publications and textbooks and provides continuing education programs for dental teams.
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