There`s a right way and a wrong way to sequence a patient`s initial visit. Which scenario applies to your office?
Carol Tekavec, CDA, RDH
A "check-up and cleaning" is one of the most common appointment requests made by patients. The desire to have your teeth examined and cleaned (think "quick lube and car wash") at one visit is part of the American landscape. While receiving an exam and prophy at the same appointment is perfectly appropriate for thousands of patients, problems can arise when the two services are scheduled for a new patient.
Jane Patient recently moved to town. Her children attend a local elementary school, While dropping them off one day, Jane asks another mother to recommend a good dentist. The mother tells Jane about her dentist and suggests that Jane give her a call. The phone interview and subsequent appointment go something like this:
The wrong way
Receptionist (Judy): "Good morning, Dr. Young`s office."
Jane: "Hi, this is Jane Patient calling. I would like to set up an appointment for a check-up and cleaning."
Receptionist: "Have you been to our office before?"
Jane: "No, I just recently moved to town."
Receptionist: "Well, we can set you up for an exam and cleaning next Wednesday at 9 a.m. Will this work for you?"
Jane: "Yes, that would be fine."
Receptionist: "OK. We will look for you at 9 a.m on Wednesday."
Wednesday arrives and Jane goes to Dr. Young`s office. The receptionist is busy at the front desk, so Jane sits down in the reception room. No one calls her name and, after 15 minutes, she goes to the front desk to see what the wait is all about. Judy, the receptionist, did not see Jane come in and did not realize that she was waiting for her appointment.
Judy: "Oh, I did not know that you had arrived! Did you sign in?" She points to a clipboard at the desk.
Jane: "No, I didn`t realize that I had to."
Judy (a little annoyed): "Yes, we require all our patients to sign in when they come for their appointments or we do not know that they have arrived."
Jane (feeling somehow both embarrassed and angry and wondering why Judy didn`t simply notice her in the reception area): "Well, sorry. I have been waiting quite a while."
Judy: "Well, here is our medical-history form that we need to have you fill out before you can be seen." She hands Jane a different clipboard with a form on it. Jane returns to her seat and begins to complete the form. After another 10 minutes, she brings the completed form back to Judy, who takes it from her and indicates that she should be seated again.
Enter the hygienist
After yet another five or 10 minutes, Carol, the hygienist rushes breathlessly into the reception area and calls Jane`s name. Carol is running behind because she did not think that this 9 a.m. patient was going to show. She had not been notified the patient had arrived via the light/buzzer system in her treatment room, so she had gone to the sterilization area to sharpen her instruments. Now, the hygienist was running 30 minutes behind schedule as a result of the 15 minutes Jane waited in the reception room, plus the 10 minutes it took Jane to complete the medical-history form, plus at least five additional minutes that it it took Carol to set up her room.
Carol escorts Jane into the X-ray room to begin taking the necessary "new patient" radiographs. Jane isn`t happy. She already has been waiting for over half an hour and now she is going to have X-rays taken before she even sees the dentist! How does the hygienist know what X-rays she needs? Does this office just take the same X-rays on everyone regardless? If so, that is not a good method of handling things, Jane thinks.
Jane: "Do I really need to have these X-rays?"
Carol has heard this question hundreds of times. She knows that it will take her at least 10 minutes to expose the seven-bitewing series that the office routinely takes on new patients and then about four minutes to run them through the developer. Answering this patient`s questions and addressing her concerns will take at least 10 minutes more. Carol had 50 minutes saved for her "new patient prophy." That amount of time could be completely used up before she even gets the patient into the treatment room!
Carol: "We take decay-detecting X-rays on all of our new patients. These X-rays also will show us the height of the bone support around your teeth, which is very important to know."
Jane: "I understand that some X-rays are necessary, but I don`t like to have X-rays taken too often. I just had a chest X-ray taken last month!"
Carol (in her most reassuring tone): Dental X-rays use much less radiation than a chest X-ray. Plus, we use super-fast film to reduce your exposure even more."
Although Jane is listening and appears to be a nice patient, Carol feels very much on the defensive - the way she always does when trying to discuss radiographs with a new patient who has no relationship with the office yet. Carol does not like to feel that she is talking a patient into something she does not understand the need for, even when it is for the patient`s own good! Plus, being on the defensive is not conducive to good patient relations.
Jane reluctantly agrees to have the X-rays done, but it is easy to see that she is not really very happy. With all of the delays, the few minutes that Carol had left for her appointment are now gone. Carol escorts Jane into the treatment room, only to be "buzzed" by the receptionist to let her know that her 9:50 patient has arrived.
Carol seats Jane and begins a full-mouth periodontal probing. Jane has never received a periodontal probing and asks many questions. She also is very jumpy and sensitive. Usually, Carol asks one of the chairside assistants to help her record the probing data, but all of the assistants are busy. It takes Carol 10 minutes to probe and record Jane`s mouth by herself.
During the probing, Carol realizes that Jane will need more than just a standard adult prophy. In fact, she will need to have four quadrants of periodontal scaling and root-planing. Carol uprights the chair and begins explaining periodontal disease and periodontal-scaling to Jane. Jane seems quite shocked to hear that she has a "gum disease" and will be needing more extensive treatment than a simple "cleaning."
"Nothing ever hurts!" Jane keeps repeating.
The dentist`s diagnosis
At just that moment, Dr. Young comes in and introduces herself. She senses that there may be a problem of some type between Carol and the new patient, Jane, but hopes that she can smooth things over during the exam.
She notes several teeth that need to have crowns and several teeth with cracked restorations. Dr. Young also notices the probing data and the condition of Jane`s mouth. She knows that perio-scaling and root-planing will be needed, just as Carol did.
Dr. Young: "Well, Jane, it looks like we will be needing to place some crowns on a few of your teeth, and you will be requiring periodontal treatment as well. I will talk to you at your next appointment."
With this, Dr. Young leaves the treatment room.
Jane: "What did Dr. Young mean about my needing to have crowns? Why do I need crowns?"
Carol: "Some of your fillings are worn and cracked and need to be replaced. Often, a crown is the only way to repair such problems successfully."
Carol reclines the patient`s chair and attempts to address at least some portion of the perio-scaling that Jane needs. Jane is extremely sensitive and uncomfortable during the procedure. She keeps asking to rinse and coughs repeatedly.
Jane: "Am I bleeding?" (Her voice indicates alarm because she has noticed blood on the neck napkin.)
Carol: "A little." (She is quickly developing a terrible tension headache).
Carol finally completes perio-scaling on three teeth in the upper right quadrant of Jane`s mouth. She uprights the chair and begins to explain home care to Jane.
Carol: "You will need to begin using dental floss at least once a day, brush at least twice a day, and get this prescription for chlorhexidine. It will come with instructions." (There is no time to demonstrate anything.)
Jane: "I need a prescription for my mouth! I never dreamed that I would need so much treatment. This is really very upsetting. I can hardly believe that I need to have something special for my gums. My previous dentist never mentioned anything about any of the problems you and Dr. Young have told me about."
Carol tries valiantly to calm Jane and to further explain her problems. The hygienist is very anxious because she is going to be so late in getting to her next patient. She hurriedly fills in a routing slip and hands it to Jane to take to the front desk.
Carol: "Please give this to the receptionist, and she will set you up for your next appointment."
With that, Carol aims Jane toward the front office. Carol then quickly retreats to her treatment room to begin the lengthy clean-up, disinfection, and sterilization process.
Jane wanders up to the front desk with her routing slip. The receptionist, Judy, asks her if she needs another appointment.
Jane: "I think that I do."
Judy looks at the routing slip, which contains the charge for today`s visit, but no information about what Jane`s next appointment should be for.
Judy: "Let me just go back and get your chart." She hurries to Carol`s treatment room and retrieves Jane`s chart. Unfortunately, because of all the problems and delays during Jane`s appointment, Carol has not been able to complete Jane`s progress notes, let alone make any notations concerning future appointments. Judy looks at the initial charting and periodontal probing and sees that Jane will need crowns, perio-scaling, and root-planing.
Judy: "It looks like you will need to have the rest of your root-planing completed and several crowns," she tells Jane.
Jane: "Several crowns! How many?!"
Judy: "Five crowns and full-mouth root-planing."
Jane: "Five crowns! How much is all of this going to cost?"
Judy: "You do have insurance, which will cover a portion of the charges. Each crown is $650 and a full-mouth root-planing is $620."
Jane runs through the math quickly in her head.
Jane: "So the total charge for five crowns and this so-called `root-planing` is going to be $3,870!!"
Judy: "Yes, plus the charges for your exam and X-rays and the beginning of your perio-scaling today. The routing slip indicates that the exam and X-rays are $140, plus the charge for perio-scaling for three teeth is $125. Today`s charge is $275. We will subtract what you have paid toward this quadrant of scaling for the three teeth done today when the rest of the teeth are scaled."
Jane: "You are charging me $275 and only three teeth have been treated?" She is very upset!
Judy: "We did not know that you would need extensive root-planing when we set up your cleaning appointment."
Jane: "All of this seems very strange to me. Can`t you bill my insurance for what was done today?" She is quite suspicious of this office. Too much is happening too soon, and costing entirely too much.
Jane: "Can`t you bill my insurance for what was done today?"
Judy: "I`m sorry, but Dr. Young does not accept insurance payments directly. We expect all of our patients to pay for services when they are rendered. I will give you a statement that you can send to your insurance for reimbursement."
Jane is exhausted.
Jane: "Ok, whatever!" She fills in a check and leaves the office without setting up another appointment to complete her perio-scaling or to begin on the crowns that she needs.
When Jane reaches her car, she uses her cell phone to call her husband, her next door neighbor, and the mother of the classmate of her child to tell them about the terrible experience she has had at Dr. Young`s office.
Jane will not be coming back to Dr. Young`s office! Mismanagement of her first appointment - and the scheduling of a "cleaning" and "new patient exam" at the same time - have resulted in extreme stress and duress to the hygienist, receptionist, and dentist ... and complete rejection of the office by a potentially good patient!
The right way
What could have been done differently?
Let`s go back to Jane`s first contact with Dr. Young`s office and see how the entire visit could have been coordinated in a more organized and successful fashion.
Receptionist (Judy): "Good morning, Dr. Young`s office. This is Judy."
Jane: "Hi, this is Jane Patient calling. I would like to set up an appointment for a check-up and cleaning."
Judy: "Have you been to our office before?"
Jane: "No, my family and I just recently moved to town."
Judy: " Well, I can set you up for an exam next Wednesday at 9 a.m. Will this work for you?"
Jane: "Yes, that would be fine."
Judy: "This appointment will be to see Dr. Young, but not the hygienist. Dr. Young likes to see patients first before scheduling any cleanings or other treatment."
Jane: "Well, I really would prefer having both my exam and cleaning done on the same visit. I have small children and I can`t be away from home for very long."
Judy (knowing that typically everyone needs some type of cleaning, but understanding the importance of not scheduling a new patient exam and hygiene visit at the same time): "I understand how difficult it can be with small children. However, Dr. Young likes to determine if her patients need a cleaning before scheduling it." (Emphasis is placed on the word "need.")
Jane: "Well, I guess that makes sense." (Jane still really wishes that she could have the cleaning done at the same time, but she certainly doesn`t want to have any procedure performed that she really doesn`t need.)
Judy: "Do you know how to find our office?"
Jane: "I think that I do."
Judy: "I will be mailing you an appointment card with a map to our office on the back. I also will send you a medical history and information form for you to complete for us and bring with you to your appointment. Filling out the forms at home will save you time while you are here."
Jane: "That`s fine."
Judy: "Do you have dental insurance?"
Jane: "Yes, we do. My husband told me that our insurance is really great! It will cover 100 percent of whatever we need."
Judy (knowing that this is impossible, but continuing to respond pleasantly and matter-of-factly): "Well, we work with all types of insurance. Each plan seems to have different coverage. Please bring any information that you have about your insurance with you to your appointment and we will work with you on it.
"Your first visit will be $95. We would appreciate it if you would cover that amount when you come in. We will help you submit your insurance afterward and will credit your account with what your insurance pays later. Should you need further appointments, we will help you submit those claims as well." (This conversation does not refute the patient`s belief that she has 100 percent insurance coverage, which would put her on the defensive. What it clearly does is delineate the boundaries the office has assigned to working with insurance.)
Welcoming the patient
Wednesday arrives and Jane goes to Dr. Young`s office. Judy is busy at the front desk, so Jane sits down in the reception room. Because Judy monitors the reception room frequently, she notices Jane almost immediately. She stands up behind her desk, smiling, and says, "Hi, you must be Jane Patient."
Jane: "Yes, good morning."
Judy: "I`m Judy. I spoke with you on the phone last week. I`ve been looking forward to meeting you! Did you bring the forms I sent you in the mail?"
Jane: "Yes, they`re right here."
Judy: "Cathy, Dr. Young`s assistant will be out to get you in just a minute. Please have a seat and I will let Dr. Young and Cathy know that you are here."
Judy begins assembling Jane`s record and let`s Cathy know her next patient has arrived.
Cathy (coming out of the clinical area, walking into the reception room and over to Jane): "Ms. Patient?"
Jane (standing): "Yes."
Cathy: "Hi, I`m Cathy, one of Dr. Young`s dental assistants. I will be taking you to meet Dr. Young, and I`ll also show you around our office a little bit."
She leads Jane down the hallway and shows her a treatment room, the X-ray area, the sterilization area, and finally, Dr. Young`s private office. Jane has a few questions about the sterilization processes used in Dr. Young`s office and uses the tour as an opening to ask them. She is glad that she did not have to simply blurt them out later to Dr. Young. Actually seeing what is done in the way of infection control and being able to ask Cathy about her concerns (in private) sets Jane`s mind at ease.
Cathy (indicating a chair in Dr. Young`s office): "Please have a seat."
Judy brings in Jane`s assembled record.
Cathy: "I want to go over the forms you brought with you today."
Meeting the doctor
Cathy reviews both the medical/dental history and the patient information form with Jane. She makes sure that all questions have been answered completely. She knows that the medical/dental history is vital for patient care and that the patient information form, which is primarily needed for billing and insurance concerns, will enable the front-desk personnel to handle finances in a speedy, yet professional manner. As they are finishing, there is a knock at the door and Dr. Young enters.
Cathy: "Ms. Patient, this is Dr. Young."
Dr. Young (extending her hand): I`m very happy to meet you. Cathy has been going over your forms with you and I wanted to see you before we go into the treatment area."
Dr. Young looks over the forms, asks Jane a few questions, and makes notes as needed. She asks Jane if she has any special problems she would like to have taken care of. When Jane answers that she is concerned about the appearance of her two front teeth, Dr. Young writes this down. Dr. Young wants to be very sure that Jane`s front teeth are a treatment priority. Few things make a patient feel less cared for than having her concerns ignored.
Dr. Young (upon finishing her notes): "Cathy, please take Ms. Patient to a treatment room. I will join you there in a minute."
Cathy and Jane move to a treatment room. They visit together until Dr. Young comes in. When the doctor arrives, Cathy reclines the chair and positions the intraoral camera near Jane to permit pointing out problem areas on the video screen.
Dr. Young: "First, I want to take a look at your mouth." She uses the camera to show Jane areas of concern and performs a periodontal-screening, explaining what the numbers mean. (According to the American Academy of Periodontology, when a perio-screening exam reveals a reading of 3 in two sextants or a 4 in one sextant, a comprehensive periodontal probing usually is recommended. A comprehensive periodontal probing can be done by the hygienist at a subsequent appointment).
Jane has several deep-pocket areas and heavy calculus. Both of these problems are easily seen on the video screen, and Dr. Young takes several photographs.
This portion of the exam is vital for later patient acceptance of treatment recommendations. The patient may have never realized that periodontal disease even existed, let alone the fact that she has acquired it. Seeing her own problems on the screen is educational and very important. So is listening to Cathy and Dr. Young discuss their findings. Jane is learning about her oral conditions and beginning to formulate an opinion about how important these conditions are. Her dental I.Q. is evolving. When the "screening" process is complete, Dr. Young orders X-rays.
"Cathy, I would like for you to take X-rays of both Ms. Patient`s teeth and her gums." (Cathy understands this as a full-mouth set of radiographs.) "After they are developed, we will complete the exam."
(While Cathy is taking the radiographs, Jane has no questions concerning the need for X-rays. Dr. Young has ordered the X-rays after looking at her mouth, so it is obvious that the dentist thinks that they are necessary. Because of this, time is saved during the X-ray process and positive feelings are fostered. After the X-rays are mounted, the exam continues.)
Dr. Young: "Ms. Patient, I will be making a record of all of the existing conditions with your teeth and gums. Any decay or other problems will be written down. I will do a cancer exam and evaluate your bite, too."
Dr. Young and Cathy work together to collect the necessary data and complete Ms. Patient`s exam. Cathy reads from a detailed charting form for initial clinical evaluations, as well as hard-tissue concerns. Dr. Young responds, and Cathy writes down what she says.
Jane listens closely during the exam. She is amazed at how much information is being assembled regarding her mouth and oral health. Dr. Young is concerned about Jane`s perio condition and talks to her about what she is seeing throughout the evaluation. When the exam is complete, Dr. Young sets the chair upright.
Dr. Young: "It is my job to let you know what is going on in your mouth and what options you might have. It is your job to decide what you want to do. Cathy is going to show you a short video on periodontal problems. What we have been talking about concerning your own oral conditions will be described in parts of the video.
"When the film is over, Sue, the office coordinator, will be talking to you about what some of our recommendations are. First, we want to address your gums and bone, and then, when they are stable, we will continue treatment with any fillings or crowns that you need. Thank you for coming to see us today, and I look forward to seeing you again."
Treatment options and payment policy
While Jane is watching the video on periodontal disease and perio-scaling and root-planing in Dr. Young`s private office, Cathy and Sue go over her chart. Sue writes up an estimate for the initial periodontal therapy that Jane will need. When the video is over, Sue goes into the office and talks to Jane about having complete periodontal charting and scaling and root-planing with the hygienist. She tells Jane that after her perio-scaling has been completed, her condition will be re-evaluated and, if it is stable, the rest of her treatment will be addressed.
She is careful to focus on Jane`s areas of concern (her two front teeth). She explains that her front teeth will be a top priority, along with her gum condition. Sue gives Jane an informed-consent form for the periodontal-scaling, as well as a written estimate to sign. Sue makes copies of these forms for Jane to keep and retains the originals in Jane`s record. Sue also fills out a treatment plan (according to Dr. Young`s recommendations) for Jane`s first stage of treatment. This form will be kept in Jane`s record so that all members of the dental team can simply check the form to know what needs to be done at each appointment. The "front office" always knows what the "back office" is doing by simply consulting the treatment plan. Routing slips and post-it notes that can be lost are eliminated.
Sue also talks with Jane about her insurance. She reiterates that the staff will help her obtain her insurance benefits, but emphasizes the fact that treatment comes first. Insurance is helpful, but it cannot be the determining factor when it comes to patients` treatment need. Sue explains that even though many patients believe that insurance will cover all of their treatment needs, this is seldom the case.
Jane is not happy to hear that her dental insurance will probably not cover all of her necessary treatment, but she is satisfied that Dr. Young`s office will help her obtain whatever benefits are available. Jane also is not happy that she has periodontal disease, which necessitates perio-scaling and root-planing. Knowing that she will eventually need quite a bit of restorative work in the form of crowns and fillings also is not the best news.
However, Jane is satisfied that Dr. Young and the staff have her best interests at heart and are telling her the truth about her condition. She feels that she is in control of what will happen to her. She has begun developing - and will continue to develop and deepen - a rapport and "trust" with Dr. Young and her staff.
Jane sets up an appointment to begin perio-scaling for the next week. She has had such a positive experience that, when she gets to her car, she calls her neighbor, her husband at work, and the mother of her little girl`s friend who recommended Dr. Young. She wants to boast about what a great office she has found and how smart she is to have discovered Dr. Young.
When Carol, the hygienist, sees Jane for her first appointment for perio-scaling, very little time is needed for explanations of what will be happening. During the visit, Carol performs a complete periodontal probing and recording and finishes two quadrants of root-planing with time to spare. Jane knows what to expect and is ready for treatment. Instead of feeling rushed and on the defensive, Carol enjoys the positive feeling of knowing that she has been able to do a thorough job on a patient who understands and appreciates her efforts.
Carol`s daily schedule is filled with patients like Jane. Carol is a good producer for the office and enjoys an above- average wage. The office has many satisfied, referring patients. This creates a steady stream of new patients coming in for treatment, making office revenue consistently good. Carol is not continually stressed out and has a good relationship with her co-workers. Best of all, her patients are receiving the type of care that Carol can be proud of providing.
Careful attention to the sequence of a patient`s initial visit with an office can reap many positive rewards. It is not enough to say, "Be nice to patients," "Don`t schedule a new patient exam and prophy on the same day," or "Do a thorough exam and chart all periodontal conditions." Exact sequences and detailed charting forms must be used to actually make the positive appointment happen.
Remember that hygiene services do not exist in a vacuum. Hygiene services are an essential, time-consuming, and expensive part of the total treatment possibilities in a modern dental practice. For hygiene services to be appreciated by patients, these services must be understood. Time spent at the beginning of the dental relationship increases the chances for a successful long-term association, as well as for complete and comprehensive treatment.
Some may wonder what Carol, the hygienist, was doing during Jane`s detailed first appointment. Instead of rushing through an unsatisfactory and ultimately rapport-destroying attempt at performing a "new patient cleaning and exam" on Jane, Carol was successfully treating a new patient from the previous week. Her time was well spent and productive for the patient in the chair, the office, and for her own peace of mind.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.
Mapping out strategies to turn new patients into established patients
For a successful new patient visit, keep these parameters in mind:
(1) The office needs to collect many types of personal information on patients. Make it easy for patients to help by mailing forms in advance. A staff member can go over the forms with patients when they arrive for their appointments. If an occasional patient forgets, help that person complete the forms rather than pushing a clipboard at them. Keep in mind that patients are more important than forms and should be treated that way!
(2) Have one person, usually the receptionist, responsible for making sure that patients are seen in a timely matter. This means that no patient should be sitting in the reception area for more than five minutes without a reason given to that individual. If the delay will be more than 20-30 minutes, the patient should be given the choice of rescheduling.
(3) Giving patients a tour of the office allows them time to "get to know" their surroundings and ask questions, particularly concerning infection control. Many patients have concerns, but don`t know what to say or how to ask questions. Often, they are afraid that they may be embarrassed or cause the dentist to become upset at the questions. The tour gives patients an opening to voice concerns in a nonconfrontational way.
(4) When the dentist sees the patient prior to radiographs being taken, the time-consuming problems surrounding "Do I really need these X-rays?" are virtually eliminated.
(5) Scheduling patients with the dentist prior to setting up any type of "cleaning" - and then providing the patient with a written estimate and an explanation of what treatment he will be receiving before it actually begins - reduces and frequently eliminates misunderstandings concerning treatment, insurance, and payment. This important appointment sequence also is critical to keeping the hygiene schedule routinely on time.
(6) Using an intraoral camera and a detailed charting system for noting needed treatment helps patients understand recommendations. When a patient can view on a video screen a large crack on an existing filling, explanations about where the crack is and what it means for the longevity of the tooth are reduced or eliminated. Photos and chart forms also can greatly support the treatment estimate/conference segment.
(7) Using videos to cover general issues greatly reduces the amount of time needed for explaining the patient`s personal conditions. The video provides general information and the staff member presenting the treatment estimate provides individualized information.
(8) Detailed chart forms provide the blueprints for patient treatment and interoffice communication. Chart forms also can be used to communicate with insurance carriers. A detailed periodontal-probing form that shows probing depths, furcations, bleeding, mobility, and recession can be completed and then photocopied. The form is then clipped to a patient`s claim form, virtually eliminating the need for lengthy "narratives."
Reimbursement is faster when requests for "more information" are avoided.
(9) Most offices dislike working with insurance, but most patients rely on it for paying a portion of their dental bills. Even patients who can afford dental treatment without insurance want their insurance to pay the maximum possible. Offices that work with insurance - without letting insurance dictate treatment - encourage new patients to return.