Balancing patient expectations, ethics

Feb. 1, 2010
I have never seen such a problem as we are having now with patients who refuse any care that is not covered 100% by insurance.

by Dianne Glasscoe Watterson, RDH, BS, MBA
[email protected]

Dear Dianne
I have never seen such a problem as we are having now with patients who refuse any care that is not covered 100% by insurance. They simply do not wish to spend any money out–of–pocket. Over the years, I have tried to educate my patients to make the best choices for their dental health. This issue has always been a challenge.

An additional challenge is the three–month periodontal maintenance issue. I fully understand that once a patient has had definitive periodontal treatment, it is inappropriate to do a Code D1110 prophy. I also understand that patients want and feel they deserve their two “free” cleanings and exams per year. If we code all their maintenance visits D4910, they will have to pay their deductible and their co–pay.

They really don't care about the appropriate way to code the visit, but they understandably want what they feel they are entitled to. Our office has never pushed the issue because we know we would have nothing but angry patients. We know the potential exists for patients to leave the practice if we do not alternate the codes D1110 and D4910. I would appreciate any ideas on how other offices have handled this issue!

Caught in the Middle

Dear Caught,

There is plenty of conflict in your post. You aptly named yourself “Caught in the Middle,” because you are caught between trying to keep patients happy and providing appropriate care. I assure you that many doctors and hygienists are struggling with the same issues, which have become more acute with our tough economy.

It is clear that you care for your patients. You stated that you can understand their point of view, and you want to help them “get what they feel they are entitled to.” I believe it is very important to understand the way other people feel, because without that understanding, we have no vantage point. In fact, many conflicts in the workplace could be avoided if people took time to understand other people's feelings.

However, what people feel they are entitled to receive and what they are truly entitled to receive can be two different things. We have to be very careful not to cross the lines of honesty and ethical fairness when it comes to third–party benefits. Let me be clear to state that we must code correctly for the services we provide. When we bend the rules to help patients receive benefits they are not entitled to receive, we have committed fraud. Unfortunately, some in our profession have crossed those lines and have paid a heavy price when their dishonesty is discovered. You state that patients “really don't care about” the appropriate codes. In the same vein, courts of law do not care that the dental professional was only trying to help the patient by coding inappropriately. If it's wrong, it's wrong.

When we think about the standards of care in dentistry, we know there are standards for preventive care (prophy) and standards for definitive care (treating a disease; i.e., gingivitis or periodontal disease). When people are disease–free, we can treat them with a prophy. People who have neglected their oral care for an extended time will rarely present with no disease symptoms. So in order to practice to the standards of care, we have to provide services that address the patient's condition.

If I take my car to a garage because it is not operating properly and the attendant says, “Well, let's just put some air freshener in your car,” that would not address the problem. I could let him do it, but it would not address the problem correctly. If the mechanic says, “You need a new fuel pump,” but I say, “Well, let's just put a new air freshener in,” the mechanic knows the air freshener will not help the mechanical operation of my car. I can demand a new air freshener, and he might do it. But he can't do it with the promise that it will address my car's mechanical issues.

If the mechanic is ethical, he will say, “Lady, putting a new air freshener in your car will not help it run better. The only way that's going to happen is if you replace the fuel pump.” On the other hand, if he is unethical, he might say, “Not only do you need a fuel pump, but you need XYZ too,” when in reality all I needed was a new fuel pump. This can go either way.

If we are practicing ethically and according to the established standards of care, we do not allow insurance companies to dictate care, especially when we know that what the patient is demanding will not address the real issues. It is your challenge to help your patients see that their benefits are meant to assist with receiving care, not cover every contingency. I used to tell people, “As long as you stay healthy, your insurance is fine. But when there are problems, your insurance is not going to cover 100%.”

I recommend the infected wound analogy. Make it real by pulling up the sleeve of your lab jacket and point to the underside of your arm with this illustration: “Let's pretend I have a six–inch gash right here on my arm. It's red, swollen, and pus is seeping from it. If I just put a Band–Aid on this gash, will that help it get better? We both know that won't help. However, if I treat this wound the right way, it will get better. Doing a ‘cleaning' for you is like putting a Band–Aid on an infected gash. It is not the correct treatment, and it will not help. The correct treatment for you involves treating the chronic infection in your gums.”

We know that long–term success with periodontal treatment is highly dependent on the frequency of supportive maintenance.

Third–party benefits can be seen as a blessing or a curse. However, please remember this: your patients will accept whatever you accept. To change how your patients are thinking, you have to change how you (and the doctors) think. Excellence in care should be central to all decision–making. You have to be clear where you stand. Is bending the rules for the patient's benefit worth the potential negative consequences?
Best wishes, Dianne

About the Author

Dianne Glasscoe Watterson, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe–Watterson for speaking or consulting, call (301) 874–5240 or e–mail [email protected]. Visit her Web site at