Asking for payment, explaining costly treatments and broaching the subject of bad debts can all be difficult and unfamiliar in the early years of practice.
Whilst at dental school, many undergraduates transform the business of asking for money almost into an art form; with the bank manager's direct line stored prominently in the mobile in case urgent funding for an emergency (such as an elective in Aruba) is instantly required! However, on graduating and moving into practice, some dentists find themselves feeling strangely uncomfortable when it comes to asking for payment.
Don't sell yourself short
This is in some ways understandable. It can seem slightly odd when patients start paying, significant sums of money, for clinical services that you have mostly provided free of charge at dental school. One of the first rules of business (and don't forget that to be successful, a dentist needs to be equally proficient in both business and clinical matters) is not to underestimate your own value. As a dental professional your patients will want you to provide the best treatment for them, and generally will be willing to pay accordingly.
There are, however, certain practical and ethical issues that should be considered in relation to setting and collecting your fees. The items listed below all require a little extra thought since they have a particular tendency to inflame and escalate patient dissatisfaction to a level that could precipitate a formal complaint when you ask for payment:
- Pain
- Violation e.g. patients feeling that they have been talked into treatment that they don't need, or which is of doubtful benefit to them
- Loss of dignity (or a perception that they were not treated with respect)
- People problems
- Unexpected consequences - e.g. the need for remedial treatment
Calculating, quoting and collecting fees
Patients have a right to know, in advance of treatment, how much their dental treatment is likely to cost. Here are some tips for avoiding problems:
1. Ensure that the patient is aware of the anticipated fees at the outset of the treatment. Warn patients if these fees might increase for any reason (for example if it is not possible to confirm a precise, definitive treatment plan until the prognosis for certain teeth has been established, or until you have had a chance to assess the tissue response and/or patient co-operation).
2. Keep the patient informed if it becomes necessary to alter the treatment plan (and hence, the fees charged) as the treatment proceeds. Actively involve the patient in these decisions, which are a fundamental part of the consent process. If there are alternative treatment options, give the patient a fair and balanced explanation of what they are, and how they compare - including relative costs.
3. Never make assumptions regarding the patient's ability or willingness to pay fees. By offering only the treatment that you think the patient can afford, or compromising on treatment because you think the patient can't or won't pay for a more expensive option, you are inviting trouble because the patient may later argue that they would certainly have chosen the more complex / costly option if only it had been offered to them.
4. Before chasing unpaid fees, always check that the patient is happy with the treatment provided. It is also sensible to check your records and x-rays, to ensure that your treatment could withstand the rigorous scrutiny of authoritative professional colleagues. Outstanding fees should only be pursued from a position of strength, because it is almost inevitable that a patient, who is unhappy with the treatment provided, will respond to any claim for unpaid fees, by making a counterclaim, which alleges negligence or some kind of breach of contract on the part of the dentist. If you might be vulnerable to criticism in respect of any aspect of the treatment provided, think twice before pursuing unpaid fees. This avoids the embarrassment of having to back down at a later stage.
For the record
Keep a meticulous record of all fees quoted, charged and paid, and any discussions in relation to the financial aspects of treatment. Record each stage in the process of collecting fees, particularly if the patient seems reluctant to pay the amounts due. Such records should include notes of face-to-face conversations and telephone calls, and copies of any correspondence with the patient. These records should be kept with, but ideally separate to the patient's clinical records.
Confidentiality
It is important to respect a patient's dignity and privacy when dealing with the financial aspects of their treatment. Wherever possible, sensitive financial discussions should take place in private, out of the hearing of other patients. Any conversation regarding unpaid fees should only involve the patient, or someone that the patient has specifically authorized to speak on their behalf and nobody else.
Ethical considerations
When dealing with the financial aspects of patient care, many of the practical issues are inseparable from the underlying ethical considerations that underpin them in a professional healthcare environment. These include:
- Duty of care - A patient's best interests must remain paramount at all times. Dentists should never be tempted for reasons of financial gain to recommend or provide treatment that is not in a patient's best interests.
- Standards - Dentists have a duty to provide treatment with a reasonable level of skill and care. They are expected to have up-to-date knowledge and they have an ethical duty to suggest a referral if any treatment challenges their own experience/expertise.
- Honesty - Patients have a right to expect that information given to them about their treatment will be honest and truthful. Untrue, misleading or deceptive statements, information or behaviour should be avoided. Patients should be made aware of all material facts about treatment options. A failure to disclose such facts, especially when motivated by the prospect of financial gain, is likely to be viewed as an act of dishonesty.
- Morality and decency - The public has a right to expect that dentists will behave with fairness and integrity. A patient's dignity, autonomy and rights should be respected at all times and no treatment plan should ever be motivated by greed, business advantage or financial gain to the patient's detriment.
- Professional reputation - When advertising or promoting treatment, or its cost, dentists should be mindful of the need for professional propriety. The way in which dentists conduct their financial dealings with patients has a direct impact upon public confidence and trust in the profession
Common problem areas
- Demanding fees for treatment which has failed, or which the patient believes to be unsatisfactory
- Demanding fees which are greater than the patient had been led to expect, or greater than those which the patient had agreed to, without proper explanation
- Charging fees at a level which the patient believes to be excessive
- Charging fees for treatment or services which the patient perceives (rightly or wrongly) you have not provided
- Charging fees for treatment which the patient perceives (rightly or wrongly) as being unnecessary
- Referring the patient to a second dentist, who then charges the patient to put right problems resulting from the original treatment that you had provided. In such situations it may be more sensible to come to a private colleague-to-colleague arrangement whereby the second dentist does not charge the patient directly, but instead invoices the original dentist for any 'remedial' treatment.
Communication is the key
As with most aspects of modern dental practice, good communication forms the basis for all your financial dealings with patients. The way in which it is communicated is very important.
In particular, there are a number of basic considerations you should make before committing yourself in writing. This includes patient letters, information sheets, estimates, quotations and requests for payment.
- Don't be too hasty
- Who is the communication aimed at?
- What are you trying to say?
- How should you say it?
- Could this be read by someone who is not the intended recipient?
- What impression does it convey?
- How might the communication be misinterpreted?
Failure on the part of the patient to pay promptly for the clinical services you have provided can be extremely frustrating and there can be few dentists who will not, at some stage, have felt the urge to unleash a threatening letter to a patient who, for one reason or another, is being particularly slow in settling their account. If you are tempted to write such a letter, put it in a drawer and look at it again twenty four hours later when you are feeling less angry.
No refunds?
Dentists have many different attitudes when it comes to either waiving or refunding charges for treatment. Some dentists can be unwilling to refund their fees to a dissatisfied patient, particularly if they feel the treatment has been properly provided. When valuable time and materials have been invested, dentists can naturally be reluctant to 'foot the bill' simply because a patient has expressed some dissatisfaction. However, in some circumstances, the refusal to waive or refund fees cay be a false economy if the patient subsequently makes a complaint. It can be a difficult decision, but it is always worth considering which path is likely to cause the least problems in the long run.
Summary
- It may take a while to get to grips with patient finances. Once the novelty of watching fees accumulate in your bank account has passed, there are the additional matters of creating a transparent costing for treatment, obtaining, recording and banking day to day payments and following up patients who asked to be sent an account.
- Although you may delegate some of this work to a practice manager or receptionist, you need to develop your own level of confidence in dealing with the financial aspects of dentistry. Most of the problems involving fees can be eliminated if you will take the time to communicate effectively with all your patients.
- Involve every member of your practice team in the process. This is an area where a team approach to risk management can really pay dividends. Avoid some of the problems by creating a system for handling money in your practice. Speak to an accountant if you need some help with the bookkeeping, because at the end of the day this is the person who will have to audit your books. You might like to create a short written policy which can be discussed with all staff members, and which covers all the key areas discussed above.
- Handling money and dealing sensitively with fee collection is an essential skill in general practice. With a little training and attention to communication skills, you can increase the ability of practice staff to collect fees when due, and to deal effectively with the reluctant payer.
- Don't assume that every patient who expresses dissatisfaction is trying to avoid payment of an account.
- Dealing effectively with money improves practice profitability, saves time and expense in chasing unpaid fees, minimises patient dissatisfaction and complaints and can improve patient satisfaction and new patient recommendations, by complementing a high standard of patient care, ethics and professionalism.