January 2013

EGP-Feb13

Click Here to Read the First Issue
(w link to PDF download)

Welcome to Efficiency In Group Practice

Tips From The Trenches

Documenting Diagnosis: Now More Than Ever

Competition is What You Make Of It

Electronic Dental Records and the Efficient Group Practice

Efficiency in Managed Group Practice

How Helping Them Can Help You

Everything You Need to Know About Dental Office Fraud

Visual Accountability for Higher Case Acceptance

REAP the Benefits of a Great Handoff

The Efficient Clinician

Top Line Team Members Bottom Line Success

 

Top Line Team Members Bottom Line Success

By Rhonda Mullins

Hiring top line team members results in bottom line success because motivated and dedicated team members not only share the practice vision, culture, and mission, they feel invested in the practice. When employees feel mentally and physically invested in the company their loyalty, performance and production increases. Highly skilled, motivated, and self-directed staff and team members are crucial to the growth of dental practices today. This article enumerates the many benefits to hiring ideal employees, discusses the importance of the work environment and the employer/employee relationship in attracting and retaining top line team members, and highlights the ways a superior staff working to incorporate care-driven® dentistry, the 4 Capital Quadrants, and the C4 YOURSELF® concept translates into higher case acceptance, enhanced patient satisfaction, and increased
patient referrals.

Objectives
Upon completion of this article, readers will able to:

  • List steps to attract and hire top-line employees.
  • Describe specific methods for keeping employees motivated.
  • Discuss how the relationship between employee and employer affects the success of a practice.
  • Explain why hiring dedicated employees results in practice success.

Introduction
Managing a business presents many challenges particularly for dentists whose primary interest is not to manage, but to provide first-class dentistry. Assembling a “top line” team is foremost among them. When you hire, encourage, and galvanize highly skilled, motivated, and self-directed team members, they embrace and share the vision and mission of the practice which ultimately leads to bottom line success. Well-defined roles and responsibilities allow employees to concentrate their energies and incorporate the 4-C concept – Credibility, Communication, Competence, and Care into their daily routines. As a result they are able to relate to and understand patient needs and desires, and translate those into experiences that lead to an increase in case acceptance, referrals, and overall better treatments.
The most valuable asset of any business is relational capital.1 The relationships between employer and employees, and the dental team and patients, are key to the sustainability and growth of the practice. Staff, dental assistants, and hygienists are especially vital to the dental practice because of the nature of dentistry. Patients have more contact with dental staff than the dentist. Their first impression of the practice is gleaned from the front desk staff either in person or by phone, and we are all familiar with the saying “first impressions are lasting impressions.” Next, they visit the hygienist, at least twice a year, and if they manage their own oral health successfully, will rarely see the dentist. Therefore, attracting, hiring, and retaining top-line team members is an investment in the success and future of your dental practice.

Attracting Top Line Team Members
Today’s professionals are looking for the total package: job security, an attractive financial package, benefits, a challenging work environment, professional fulfillment, opportunities for growth, flexibility, empowerment, recognition, and rewards.

Flexibility – today’s employees seek balance. It is important to their quality of life. A flexible schedule provides the freedom to meet family responsibilities and obligations, spend time with family and friends, and to pursue personal growth.

Room to lead and grow – micro-managing your employees sends the wrong message. They are high functioning, intelligent adults and wish to be treated as such. Show confidence by allowing them the freedom and space for problem solving, decision making, and to apply their own unique strategies to handle situations and reach professional goals. Also, provide opportunities for growth and leadership positions.

Energize them with your vision – speaking confidently and with emotion regarding your goals and vision for your practice, and their potential role and contribution to the future of the practice, will inspire them to share that vision and apply their knowledge and skills toward reaching your goals.

Financial package – although research indicates that money alone does not attract and retain employees, it can speak volumes. Underpaid is undervalued, but a generous salary shows the employee that their knowledge, skills, and experience are a valued contribution to the practice or company. Benefits, bonuses, and paid vacations also attract employees.

Environment – environment is a huge selling point for employees. Much of their day is spent at work and an oppressive atmosphere does not create job satisfaction or attract patients. Employees, just as patients, prefer a warm and friendly atmosphere rather than a sterile, indifferent environment.

Hiring and Retaining the Ideal Employee
Although an important investment of resources, interviewing and hiring the “right” employee can be time consuming
and imbued with miscues. Cognizance of your practice culture is crucial to minimizing such mishaps. Defining your approach in the three keys areas of your practice will help you identify what qualities are desirable in a new hire. Listing the managerial characteristics of your practice, the clinical, and the cultural characteristics will help focus your efforts. For instance, at what pace does activity in each area proceed (is it laid-back, rapid, intense), what conduct and demeanor is expected of employees in respective areas (should they be open and friendly, or serious and at attention), is a certain volume maintained – are boisterous personalities welcome, or is a quiet, reserved personality a better fit? Once you are aware of your workplace culture you can focus on the personalities, strengths, and talents of perspective hires that align with your practice atmosphere, vision, and mission. Hiring employees who share your vision and work ethic reduces potential future conflicts and turnover.

Turnover can be costly in any business but in dental practices losing an employee – particularly a hygienist – can mean losing patients loyal to that employee, making it even more damaging. So, once you attract the best employees how do you retain them? According to research the number one reason employees leave their positions is their supervisor. Therefore, being an effective leader is crucial. The interpersonal dynamics between the dental team and their dentist is key to employee retention.

Incorporating the C4 Yourself Leadership and Management practices will help make you an effective and successful leader.

(C1) Credibility – employee surveys indicate that credibility and employer honesty are the two most important aspects regarding their relationship with their supervisor.2 According to employees it is important that leaders can be believed, trusted, respected, are credible, and lead with integrity.

(C2) Communication – communication is of the utmost importance considering 70-90% of a supervisor’s day involves communication.3 Effective leadership is highly dependent upon an open, honest, clear, style of communication as well as responsiveness to employee needs and concerns.

(C3) Competence – employers who display knowledge and expertise in their field gain the respect of employees. Competence is attained via training and education. Stay abreast of new developments, procedures, materials, and technology in your field and continue to incorporate them into your practice. Employees will take pride in providing state-of-the-art services, and these positive feelings will be noticeable in the way they speak, act, perform their duties, and most importantly, the way they treat patients.

(C4) Care – research shows that not only is job satisfaction higher when employees feel their employers care about them, but their work quality and productivity increases.4 Provide recognition and appreciation for employee contributions, achievements, growth, commitment and dedication. Not only are employee efforts analogous to their feelings of being valued4 but studies show that appreciated employees display a higher level of commitment and loyalty resulting in increased job satisfaction, decreased absences, and higher retention rates.

There are numerous ways to show employee appreciation, and the easiest and least expensive is praise. You can praise them privately, or publicly during a company meeting or in a company newsletter. You can also reward them with something more tangible such as tickets to the theater, a sporting event, a visit to the spa, or a day off with pay.

The 4 Capital Quadrants
The popularly held belief that the right amount of money will keep any employee happy is a misnomer. The importance of salary should not be understated, but there is more to job satisfaction than money. As a business person and employer it is wise to be familiar with the relevance of the 4 Capital Quadrants: Relational, Reputational, Educational, and Financial Capital. The C4 Yourself Leadership and Management practices mesh effortlessly with the 4 Capital Quandrants. Relational Capital refers to how you interact with, relate to, and treat your fellow workers and patients. Caring and respect are key. While salary and benefits are still important, employees want to feel valued and know that their contributions are appreciated. Research indicates that respect, appreciation, and a sense of purpose are rated higher among employees than salaries or other tangible benefits.

Positive employer/employee relations directly affect Reputational Capital which in turn influence profit. One of the three most acknowledge forms of leadership (the other two being Laissez-fair and Autocratic) Democratic leadership has been proven the most successful. Democratic leadership relies on employee input and allows each employee the space to be themselves while contributing their skills and talents to the company. A democratic employer respects and values employees, and appreciates their individualism and creative ideas. In the dental practice this takes the form of team collaboration when decisions and/or changes need to be made. Everyone is welcomed and encouraged to contribute their ideas and feelings, resulting in a deeper commitment to the practice. While willing to provide guidance when needed, democratic employers encourage their employees to solve problems and make decisions on their own when required. In an effort to fulfill the need for self-actualization, together employer and employee establish professional goals for the growth and development of the employee within the practice or company. Democratic leadership tends to be one of the most effective styles of leadership because it establishes a positive, caring environment in which employees feel valued and as a result motivated to provide their ultimate performance. A dominant aspect of the Democratic Leadership style is how the employer conducts themselves. Rather than blame or punish when a conflict, mistake, or misunderstanding presents itself, the employer considers their employee’s feelings and shows compassion and understanding utilizing the situation as a learning experience that everyone can benefit from. Primarily, the leader conducts themselves with honesty, integrity, and empathy earning the admiration and respect of employees.

It has been proven that ineffective leadership affects staff morale, patient satisfaction and, ultimately, practice success. A Harvard research study based on neurological and psychology determinants has proven that a leader’s attitude, actions, and mood can make or break a business because employees are so tuned into their employers that their actions and reactions permeate every aspect of the organization, especially employee attitudes and performance.

The study demonstrated how the presence of another person can change our physiology, including cardiovascular functions, sleep rhythms, and attitude, i.e., a calm presence can reduce blood pressure, and the release of harmful fatty acids. Therefore, it is important to strive to be a positive and calming force within your practice or organization and to maintain positive relationships with employees.

Educational Capital is the investment made in your and your team’s knowledge and professional growth. A leader who invests time and finances in the increased knowledge of their profession not only gains the respect of employees, but also patients. Equally, leaders who invest in the continued education of their employees benefit from their advanced knowledge and skills, and from their increase in job satisfaction, loyalty, and long-lasting commitment. With every CE course that a dentist or team member takes, every degree held by each employee increases the value of their contributions and increases the value of your practice.

Reputational Capital is highly regarded. More often than not, when asked “How did you hear about us?” the answer is by word of mouth, from a relative or a friend. There are many facets involved in building a good reputation for your dental practice including quality, efficiency, dependability, commitment, relational capital, and atmosphere. A good reputation attracts patients, increasing opportunities for profit, but it also attracts employees. Practices that provide a friendly, family atmosphere while offering efficient and quality treatments gain a good reputation and consequently are inundated not only with new patients, but with applications for employment.
Financial Capital is defined as the money, goods, or services used to generate income, your practice space, instruments, staff, team, yourself and the technology all fall within the definition of Financial Capital.

The congruency of C4 Yourself Leadership and the 4 Capital Quadrants becomes apparent when you realize that the four C’s in C4 Yourself Leadership and Management Principals fall within Relational Capital and build Reputational Captial; C3 and C4 fall within Educational Capital; and Relational, Reputational, and Educational Capital are all sources of Financial Capital creating a metric for successful leadership and management. However, to maintain a successful practice it is imperative to go one step further by incorporating Care-Driven® dentistry into the equation.

Care-Driven® Dentistry
Care-Driven® dentistry benefits everyone involved. Since it is based on cultivating trusting, respectful, caring, long-term relationships with patients it too relies on the four C’s defined in the C4 Yourself Leadership practices. The same values important to employees in their relationship with their employer are equally important to patients in their relationship with the dentist, staff, and team. Studies show that unsatisfactory relationships between the patient and dentist are the major reason patients change dental practice providers. Strong patient/dentist relationships are cultivated using the four C’s: Credibility, Communication, Competence, and Care.

Conclusion
All people appreciate and prefer being treated with kindness, caring, and respect, and all people want their practitioners to be trustworthy and competent. These values keep patients returning, and it increases employee retention. Human relations are meaningful to all involved and a sense of purpose is especially meaningful to employees. Serving a purpose leads to job satisfaction resulting in job retention. In the end, all three systems contain interrelated parts contributing to the successful performance of the practice and benefitting the dentist, dental practice, employees, staff, and patients.


Rhonda Mullins is a dental practice development strategist who combines business savvy, clinical aptitude, and transitional analysis to inspire successful changes for her clients. An L.D. Pankey Institute and Dawson Academy trained dental laboratory owner/technician, Ms. Mullins launched her consulting company in 1993 and today is an accomplished lecturer, educator, and consultant and has authored numerous articles in dental publications about achieving optimum results through practice transformations and incorporating Care-Driven® dentistry. For more information Ms. Mullins can be reached at: Rhonda@rhondamullins.com or rhomullins@gmail.com

The Efficient Clinician

For almost a year now, Dr. Michael Sesemann and his team have been using what he calls a “revolutionary advancement in posterior dentistry”. “Thanks to Ivoclar Vivadent’s Tetric EvoCeram Bulk Fill composite, we have changed the way we do things and I can tell you emphatically that we’ll never turn back!”

This protocol was created to streamline the posterior composite placement procedure, to offer an option that is easier to apply and saves a significant amount of time while maintaining the integrity of the composite restoration. According to Dr. Sesemann, it gives him the quality esthetics he wants along with the metrics that are so important to a posterior composite—durability, minimal shrinkage, good marginal adaptation and easy placement.

Based on numerous requests from dentists over the years, Ivoclar Vivadent began researching the viability of a one-material bulk fill technique almost seven years ago. The goal was to create a consistently reliable, easy to use composite filling material for use in Class II posterior restorations. After a lengthy research and development process, the team came up with what is now Tetric EvoCeram Bulk Fill – a material that incorporates a light initiator that allows it to fill cavity preparations up to 4 mm in one layer applications, and be sculpted and cured without the need for a capping layer. This polymerization booster ensures the complete curing of 4 mm thick increments in 10 seconds, and the material’s Shrinkage Stress Reliever decreases overall shrinkage volume experienced during polymerization. According to Dr. Sesemann, using this treatment protocol has all but eliminated the dreaded white line at the margin as well as shrinkage that might lead to cracks, gaps, leakage or post-operative sensitivity.

At Efficiency in Group Practice, we’re always on the lookout for products, techniques or a combination of the two that accomplish your goals of saving time, saving money, making life easier for you and your team while producing excellent results for your patients.

For Dr. Sesemann and his team, the biggest benefits Tetric EvoCeram Bulk Fill has brought to his restorations are reduced shrinkage and adaptability. “It adapts well and it’s consistent. In many cases, we can fill up a restoration, sculpt the material and cure it without any further preparations. We used to use a fourth generation bonding material to create a strong hybrid layer to avoid post-op sensitivity, but with Tetric EvoCeram Bulk Fill we can use total etch or selective etch bonding agents which saves us a lot of time.

It also takes less time to cure and place the composite. After using it for almost a year, I can safely say that it takes us a good 30 percent less time than it used to in order to complete a direct posterior composite. That’s a huge savings. Equally important, we haven’t had a single patient complain about post-op sensitivity.”

To date, the team at Ivoclar Vivadent has received overwhelmingly positive feedback from many of the clinicians who have used Tetric EvoCeram Bulk Fill. They put the product in the hands of top cosmetic dentists, such as Dr. Sesemann, and many of them are saying it has exceeded their expectations. They’re happy with the esthetics, the marginal integrity, how easy it is to use and how well it blends.

“I’m very particular,” Dr. Sesemann said. “I have a higher end cosmetic practice and my patients generally have high expectations. The results we achieve are excellent so I feel confident in saying that my team, my patients and I all win.”

REAP the Benefits of a Great Handoff

By Angela Davis-Sullivan

We all know that we can schedule and perform financial tasks from the clinical side, but there are still occasions that we need to handoff a patient to another team member. We also realize that the tasks of scheduling and making financial arrangements from the back are still a challenge for some offices. In those cases the office could benefit by developing a system for an easy and effective handoff of the patient.

Let’s face it, we all want an easy way to handoff our patients to other team members, the problem is we can’t always remember what information we need to convey to each other. Using the letters REAP, is a great way to handle the handoffs, especially from the clinical team to the administrative team. The purpose of the handoff is to verbally tell team members what we did, and it allows the patient to hear it again. When doing a handoff you can use the guide REAP.

The R is for Review. What this means is to review out loud with the patient and team member what was done today. Reviewing allows you to reiterate what was done and allows the team member to double check it against what was posted.

The E is for Educate. Use this to inform patient and team member about what we need to do next. Educating the patient about what their upcoming appointments will involve. This is a great way to include the administrative team on what has been scheduled or what needs to be scheduled. By doing this during the handoff it helps to eliminate the confusion about the patient’s reason for return.

The A is for- appoint. Seems simple right? Of course we make their appointment. Making the next appointment is often over looked. So after we use educate, we go on to appoint. Assume they want to schedule, and find out if they prefer mornings or afternoons and get them scheduled. If you are scheduling from the back (which is great!) then use this time to let the administrative team know you have them scheduled. This reinforces it for the patient.

P is for Payment or Payment Arrangements. We all know how important this step is and we can’t leave it out. In the handoff this can be about making financial arrangements or telling team member how the patient plans to pay. The beauty of this is that it is said in front of patient and the team member. This really helps to cut down on the confusion and it is documented as well.

So a handoff to the admin team from the clinical team could sound like this:

“Ms. Kendrah did great today! We completed the crowns and fillings on the upper left today. I reminded Kendrah that the next area to focus on is the crowns on the upper right. We want to get those restored before she starts having pain. I have her scheduled on the 30th at 9am for those. Kendrah is also going to make payments in two parts; here is the financial sheet for that. Thanks Kendrah- it was great seeing you today. Cindy will take great care of you!”

You could be less specific about treatment if you are speaking in an area in which other patients are present. The steps are the same and it can be complemented with written communication by using a routing slip. The important thing is that the handoff keeps the other team member informed. It could be, “Ms Kendrah was a great patient today and we completed the upper left. I reminded her about the upper right for next time, and I have her scheduled. This is the financial arrangement for that appointment.”

Another example is for when scheduling and or financials are not being done chair side.

“Ms Kendrah did great today – we finished the crowns and fillings on the upper left. I talked with her about the need for the treatment on the upper right and she is ready to schedule. Kendrah – you are in great hands. Cindy will take care of you, get you scheduled and share with you the payment options for the upper right. Thanks Cindy, see you next time Kendrah!”

Just remember it is important to follow the REAP, so all the information is exchanged and shared with the patient and team member. Review, Educate, Appoint, and Payment. This technique allows you to relay important information to the patient and make your team member look great too!


Angela Davis-Sullivan has been in dentistry for more than 25 years. She has held almost every position in the dental office eventually becoming office manager and new patiaent coordinator for over 10 years. She joined Productive Dentist Academy in 2006 as a specialty coach working with and mentoring office managers around the country. In 2008 she became a head coach with PDA. She works with doctors and teams to obtain the results they deserve. Here specialties are streamlining systems, solidifying the team, and teaching patient communication skills. Angela can be reached by email: Angela@ProductiveDentist.com or by phone at 813-690-7531.

Visual Accountability for Higher Case Acceptance

By Dr. Todd Snyder

Today’s populations more than ever before are shoppers with the ability to have instant answers provided to them by the internet. Comparison shopping is higher than ever, occurring with virtually any product or service and is typically driven by cost alone. Patients do not possess the knowledge to properly diagnose or treat themselves and thus must still rely on the dental practitioner. Patients’ perception of dental work is that it can be shopped like a common commodity or brand product as opposed to a service based custom product which is not comparable.

Case acceptance is critical to the survival of a dental office and during a recession it is more important than ever to possess the technology and skills to motivate patients to proceed with treatment. Pointing at radiographs to justify the need for treatment has never worked well, nor has talking to the patient in dental terminology. Patients are going online and educating themselves more than ever, looking for second opinions to corroborate their own denial to a problem being present or avoiding treatment because they cannot justify the need or expense. It is important to have technology that is simple and visual for anyone to perceive that a problem potentially exists and can compel someone to act or better yet receive recommended dental treatment.

Has the explorer become ancient history? Almost. Other than the need to check a margin on an indirect restoration there is virtually no need for the use of an explorer any more. The invention of the intraoral camera has been around for many years and has allowed us to show our patients when a crack is present or a filling is failing as well as many other types of visually perceivable problems. The ability to visually see and comprehend what is being diagnosed is one of the most motivating tools that we can possess. To utilize our senses can be a very powerful and motivating tool to assist the dental team in the diagnostic process with our patients. For example, the Diagnodent by Kavo is a diagnostic tool that uses the sense of sound to get the patient involved due to the noise the device makes when there is a change in the density of the tooth structure. The patient is instructed that if the device makes a noise that typically would relate to the patient and practitioner that some level of damage has occurred to the tooth and could necessitate preventive or minimally invasive treatment or potentially a more invasive filling. If the audible noise or “buzzer” went off it was simple, the patient would typically start counting in their head how many times the device made a noise simply out of concern. After the exam the patient would then typically state out of concern how many cavities they thought they had heard and look to the dentist for guidance.

Even though patients are told they have a cavity or decay in a tooth it is amazing how patients still tend to block out the need. Furthermore an ordinary intraoral camera image with stain present in the occlusal grooves of a tooth may not be a cavity but can look like one to any untrained patient. Even with the ability to see small cavities with the assistance of an intraoral camera, patients still did not possess the training to perceive what was or was not a cavity. Thus pointing to an actual image of a tooth with a cavity still for many patients would not motivate them to move ahead with dental treatment because they don’t know what they are looking at, to them it looks like a tooth with some stain on it. Sometimes a cavity can look like a stain such that a simple image from an intraoral camera did not sell the patient on the need for treatment.

The newest type of technology may remove the patient’s concerns once and for all. For the first time ever the patient is capable of seeing their tooth with an identifiable reference for decay. They are now able to visually see decay in the form of an image of their tooth utilizing fluorescence to make decay visible and simple to distinguish to even an untrained eye. The patient that questions the diagnosis will only have the same results reproduced upon seeing any dentist with the same technology applied. Anyone not utilizing the technology may be missing out on potentially undiagnosed pathology for their patient’s benefit. With research having shown that the common dental explorer is no better than a coin toss at diagnosing a cavity; it should be eliminated from the diagnosis process and saved for evaluating marginal adaptation of indirectly fabricated restorations.

The justification for fillings or indirect restorations is finally at hand. The SOPROLIFE from ACTEON North America provides not only the dentist but his patient with the ability to see an image of the actual tooth in question with different areas highlighted by various colors signifying the density of the tooth and thus to infer tooth decay. Upon illuminating a tooth if there are red areas apparent, it is easy for both the dentist and to the layperson/patient whereby it allows them for the first time, to self-diagnose a tooth surface area that has decay present. This should alleviate any concern by the patient that the dentist has any agenda at hand other than the patient’s best interest, a healthy cavity free mouth. The patient is now more accountable for their dental treatment and overall oral health due to seeing the red areas on their teeth which creates the motivation and visible accountability.

The hygienist can also provide more accurate suggestions to the dentist during recall exams with images already on the screen showing pathology as opposed to previous intraoral images of suspicious areas that the dentist would then need to investigate further. Furthermore the images shown by the hygienist can create concern which can then be discussed with the dentist or treatment coordinator to assist with case acceptance. The SOPROLIFE can assist the entire office to run more efficiently by minimizing the time necessary to do a periodic or recall examination with the ability to provide a more accurate diagnosis quickly for anyone to see from the patient to the hygienist, dentist, and front office staff.

The patient now has the ability to visually perceive the problem, and with this awareness they can take ownership of the problem as opposed to the dentist and his staff trying to relay the importance and significance of restoring the tooth in question. With the patient taking ownership of the problem, denial and lack of follow through with treatment should be substantially reduced.

The implementation of SOPROLIFE and its fluorescent based technology should improve any office’s case acceptance rates. The advantage for the patient is to have a potentially earlier diagnosis of pathology, more conservative dental treatment, and a higher potential to have more tooth structure for the rest of their life.

The SOPROLIFE by ACTEON North America provides the ability for traditional digital photographs to be taken with their new intraoral camera, however upon depressing a simple button on this new technology the settings of what appears to be a typical intraoral camera are changed to cause the intraoral camera to emit a light with a blue wavelength which fluoresces the tooth structure. The fluoresced tooth casts a green appearance when it is healthy and of a normal density in the absence of tooth decay. During evaluation of the teeth if decalcification is present it will appear colorless on the computer monitor. This may instruct the user to recommend some preventive measures to assist the patient so the area is not damaged further in the future. If the tooth has enough decalcification of the tooth structure then the area will appear black or red. If these areas of red or black still persist after a cleaning, then caries is confirmed

This technology (SOPROLIFE by ACTEON) is allowing pathology to be quickly and easily diagnosed. The simplicity of the image on a computer monitor will allow for higher patient awareness as to the condition of their teeth. Along with an increased perception of the pathology being present, they may have an increased level of responsibility or ownership which could drive them to make an appointment.

The use of caries indicators during the preparation procedure could potentially be replaced with the ability to use SOPROLIFE technology in ascertaining if all pathology has been removed prior to placing a definitive restoration.

The camera has four different magnification settings capable of taking images under its own normal white lighting as well as the cavity detection setting which utilizes the blue light capable of fluorescing the tooth. This allows the user to see full face images, smiles, entire arches or individual teeth depending on what is needed or desired. The camera can connect to any computer utilizing a USB port and is capable of capturing images with either a finger control or a foot pedal. The camera integrates with most existing image software or can utilize its own manufacturer’s software.

The ability for patients to see their cavities on a computer monitor with this new technology from ACTEON is more significant than anything in history for patients to be motivated in having treatment performed. Furthermore the SOPROLIFE can remove some of the concern and quell some of the denial of whether they truly have a cavity in need of dental treatment. This translates to the patient now being visually accountable for some of their dental treatment which should equate to higher case acceptance.


Dr. Todd C. Snyder received his doctorate in dental surgery at the University of California at Los Angeles School of Dentistry. Dr. Snyder has learned from and worked under some of the most sought after leaders in dentistry, refining his skills in comprehensive, extremely high quality aesthetic dentistry and full mouth rehabilitation. Furthermore he has trained at the prestigious F.A.C.E. institute for complex gnathological (functional) and temporomandibular joint disorders (TMD).

Dr. Snyder lectures both nationally and internationally on numerous aspects of dental materials, techniques, and equipment. Dr. Snyder has been on the faculty at U.C.L.A. in the Center for Esthetic Dentistry where he co-developed and co-directed the first and only comprehensive 2-year postgraduate program in aesthetic and contemporary restorative dentistry.   He currently is on the faculty at Esthetic Professionals. Additionally, Dr. Snyder is a consultant for numerous dental manufacturing companies and has had the opportunity to research and recommend changes for many of the materials now being used in dentistry. Dr. Snyder has authored numerous articles in dental publications and published a book on contemporary restorative and cosmetic dentistry.

Dr. Snyder also founded and is CEO of Miles To Smiles a non-profit mobile children’s charity that helps indigent and underprivileged children.

Everything You Need to Know About Dental Office Fraud

By David Harris B. Comm, MBA, CMA, FICB, CD, TEP

My two decades of investigating embezzlement against dentists has given me insight into the pathology of this type of fraud that is probably not possessed by anyone outside my company. Many of the people who lecture and write about fraud in dental offices are not full-time fraud investigators; they either make their living from speaking about fraud or offer a range of consulting services that includes fraud investigation but also many other services. My own company’s situation is a bit different; our raison d’etre is to investigate and remediate frauds committed against dentists. In this context we encounter hundreds of frauds annually.

Probably the question I get asked most frequently by dentists is what they can do to prevent fraud from happening in their office.

When I tell them that there is nothing that they can do to prevent fraud, they often dismiss me as either an incurable pessimist or feel that I have some financial motivation for making the statement.

I’ll readily admit that I have seen enough of the bad side of humanity to become a bit jaded. However, I have no financial motive whatsoever for telling people that fraud is impossible to prevent; if I actually had an elixir that was effective at preventing fraud, I could make a lot of money selling it.

Let me explain myself a bit. Most embezzlement in dental offices takes place because a staff member has decided that the best solution to their financial problems involves stealing from their employer. In many cases that we are involved with, these financial problems are crippling; we also see situations where the financial “problems” are really in the mind of the employee and would be classified by you or me as greed. The large economic disparity between most dentists and their employees makes stealing easy to rationalize and it’s even easier to rationalize stealing from a big, profitable insurance company (this is a pattern that we see in many office thefts – the embezzler gives little thought to the possibility of the dentist being financially accountable for this type of theft).

Once someone has decided that sticking their hand in your pocket will make their life better, the next question for them to address is how to pull it off. In this battle of wits between you and the embezzler, they have all the advantages; they know you well and are well aware of what you scrutinize, and more importantly, what you don’t. I should mention that for the frauds we see, the average seniority for thieves is about eight years at the practice. While there are certainly some people who get hired and start stealing quickly, they are often caught before they do enough damage to force you to vary your retirement plans.

No matter how hard you try, if you have any aspirations of treating more than the occasional patient, you can’t monitor every one of the thousands of financial activities that take place in your office every month. Accordingly, it is simply a question of finding out what you don’t look at and targeting that area for fraudulent activities. Examining more, or different, things will simply cause the thief to adapt their modality of stealing to conform to your changed pattern. There are hundreds of potential fraud pathways in every dental office, and you simply can’t plug them all.

I can give you a simple example — one of the recommendations of many articles on fraud is that a dentist should look at their daily activities report closely each day. Please don’t misunderstand me – reviewing your daysheet is an excellent idea because it will allow you to catch accidental omissions (and there are often enough of those to justify the time involved in this review). However, it is childishly simple to effect a fraudulent transaction that will not show up on a daysheet, so as a fraud prevention technique, daysheet review is almost useless. If you do routinely examine the daysheet, the thief will certainly know this and will find a way to bypass.

There has been a lot written on dental fraud; many articles suggest various ways to make your practice a “hard target” as a deterrent against fraud – review your daysheet, make cash deposits yourself, etc. In the two decades I have spent investigating frauds, I have come to realize that this “hard target” concept is fallacious. Employees who steal from you are driven by a powerful force and are not deterred by either your efforts to make it more difficult for them to steal or the possibility of punishment.
The hard target approach is really a carryover from what deters other types of theft. For example, installing an alarm system in your house can dramatically reduce the probability of being burglarized. The difference between your house and your practice is that the house burglar has a choice of which house to enter and will typically redirect their attention to an easier target; the embezzler in your office does not have this option and will simply adapt.

When I say that preventing fraud is an impossibility, I am not in any way suggesting that there is nothing you can do to protect yourself. There are a number steps you can take to allow for early detection of fraud, to minimize financial and other damage in the event of fraud, and to maximize recovery in the event that embezzlement does take place.

Detect it Early
The key to early detection is to know your employees and to look for employee behavior that is consistent with fraud. Here are some of the tip-offs that you should be particularly sensitive to:

  • Staff members in financial difficulty – some of the symptoms include frequent requests for pay advances, creditors calling your office, or appearing to live beyond their means. Certain types of adversity also normally create financial issues including a spouse losing their job or a going through a divorce.
  • Staff members with addictions or other compulsive behaviors. This can be difficult to spot – one visible symptom is the employee who blanks his or her computer screen when someone walks by, or the person who purchases large amounts of lottery tickets. Behaviors consistent with drug or alcohol addiction should be cause for concern.
  • Staff members who appear to be super-dedicated. This is counterintuitive, because we are socialized to value a strong work ethic and not to be suspicious of seemingly dedicated employees. However, employees who never take vacation (or only take it when the whole office is closed), drag themselves to work no matter how sick they are, or work lots of extra hours (particularly when no one else is in the office) are quite likely to be committing fraud.
  • Employees who are “control freaks” – we need to be suspicious of the staff member who attempts to be the nexus of communication between patients and the office, people who are unusually territorial, or employees who resist any of the following:
  • Upgrades to dental software
  • Changes to banking or payroll arrangements
  • Changing accounting or bookkeeping services.
  • Involvement of outside consultants

In almost every fraud in which I have been involved, several of these symptoms were present but were ignored or not properly recognized by the dentist.

Minimize Damage
There are several things dentists can do to minimize the impact of fraud on themselves. Some things must be done before a fraud is even suspected; others must be implemented once the dentist suspects there is a problem.

For example, it is essential to have a reliable data backup system, to use it regularly, to take backup media off site, and for the dentist to personally have off-site custody of a recent backup at all times.

A burglar alarm system is a good idea for other reasons anyway. If used properly (and by this I mean each staff member having their own alarm code instead of the office-wide “Unicode”), we have an effective way of monitoring staff who visit the office at odd hours, and the logs may prove to be useful evidence in court proceedings.
Using the authority levels (I.e. each employee with a unique password and permissions appropriate to their job) properly that are built into virtually every piece of dental software will both shut down certain types of fraud and make the forensic process far easier. One of my continual sources of annoyance with some of the dental software vendors is that, as a way to manage support costs, they turn much of their built-in security OFF by default, and you have to specifically request that it be enabled.
While I hesitate to even mention this, one behavior that has hurt many dentists who are fraud victims is the dentist cutting corners with dental insurance. This often involves misrepresenting the actual treatment rendered in an attempt to gain benefits for the patient. Doing this can amount to giving a “get out of jail free card” to a thief. I will never forget confronting one thief who said to me “I am a receptionist making a tenth of what the dentist makes. I know that he has overbilled insurance companies for a lot of stuff. Does he really want to play ‘chicken’ with me?” As distasteful as it was, the dentist in this situation really had no choice but to let the thief slink away without consequence.

Once fraud is suspected, it is both difficult and essential for the dentist not to let his or her suspicions show. Many dentists have worsened their positions by suddenly asking for additional reports, unpreparedly confronting staff members or engaging their accountants to “have a look”. These ham-handed attempts to uncover the fraud have often resulted in the destruction of evidence or worse. We have seen a few instances where a do-it-yourself investigation tipped off the thief, who promptly erased both the computer’s hard drive and the backup medium. In at least once case, a concerned embezzler covered their tracks by burning down the dental office.
If you have read this far into the article, it is either because you are fascinated with the criminal thought process or because you consider it possible that you are a fraud victim. If your reason is the former, I completely understand your interest; people also get enjoyment from watching crime shows, car racing pileups or sports bloopers on TV.

If you are still here because you are concerned, and if you only take away one thing from this article, it should be this – FRAUD INVESTIGATION IS NOT A DO-IT-YOURSELF PROJECT. You need expert assistance, and soon. Trying to “go it alone” or getting assistance from well-intentioned advisors (who may have excellent professional credentials, but in some area other than fraud investigation) can make things much worse. If your suspicions of fraud are not well-founded (and occasionally this happens), you may have destroyed working relationships and possibly exposed yourself to litigation. On the other hand, if your concerns are legitimate, these actions will make the ultimate investigation more difficult and may jeopardize your chances of obtaining restitution or criminal conviction against the thief.

Maximize Recovery
Although it is unusual to obtain much recovery from the thief (their lack of money is normally what pushes them to steal from you in the first place), we have had excellent success in obtaining recovery from certain other sources. Sources of recovery include:

  • Your fidelity (“employee dishonesty”) insurance carrier. This normally requires a “loss report” that must be properly prepared and submitted in a timely fashion.
  • Banks – if money was stolen by means of fraudulently endorsed checks, it is often possible to recover funds from the involved bank or banks. The banks don’t normally make this process easy, so you may need some help with this one.
  • Court-ordered restitution; obtained at the end of a criminal or civil trial.
  • Sometimes, the spouse of the thief or some other interested person ( a parent, perhaps) will fund the restitution in order to protect the reputations of all concerned in the community. This happens relatively infrequently, but is certainly welcome when it does.

Again, in this area it is quite possible for the unwary to miss opportunities or expose themselves to legal action, and expert advice is needed.

Conclusion
It’s unfortunate that embezzlement in dental offices occurs as frequently as it does, and that no practice is truly safe from this problem. However, awareness and vigilance on the part of a dentist can allow for early detection of fraudulent activity. If fraud is suspected, proper advice and assistance can allow for a quick confirmation or rejection of the suspicion. If fraud is taking place, good advice can make the recovery process go much more smoothly and can minimize the financial and emotional cost to a dentist.

How Helping Them Can Help You

The Value of Implementing a Dental-Medical Cross Coding System

By Marianne Harper

Has it happened in your practice yet – you receive a letter from a patient’s dental carrier telling you that they will not consider the dental claim until you file with the patient’s medical insurance carrier first? If your practice is like most dental practices, you have no idea how to file a medical claim and you have no idea of how you will obtain any benefits for your patient if you don’t file a medical claim first. Take notice – this situation is happening more and more frequently around the country.

Dental-medical cross coding is your answer. Learning this system is not as difficult as you might think. Implementing a cross coding system in your practice will not only help you handle the situation that the dental carriers have created but it will provide a way for you to make a significant difference in making medically necessary dental procedures much more affordable for your patients. If medical insurance will cover those medically necessary dental procedures, treatment plan acceptance can greatly improve and the accounts receivable can decrease. Also, you will find that those patients who you have helped by providing them with a way to better afford their medically necessary dental procedures will become your number one champions and they will help to market your practice. As you can see, implementing cross coding can make a significant difference in your practice.

What you may not realize is that many of the dental practice management software companies provide cross coding components to their software. So you may already have the tools to cross code. This helps to keep the costs down for implementing a cross coding system for many dental practices.

You should now see the answer to why we should make this implementation but the next question will most likely be “how do we do it”. Let me help take away the fear of learning this new system by providing several options:

  • Purchase a dental-medical cross coding manual – There are several such manuals that can be purchased. I am the author of one that is titled “CrossWalking – A Guide Through the CrossWalk of Dental to Medical Coding.” These manuals provide a basic learning tool for cross coding. In addition, these manuals should provide the medical codes necessary to file these types of claims. When deciding on which manual to choose, check to see if there is an update service for the manual that will keep your manual current with the yearly medical coding updates.
  • Even better is to combine the purchase of a manual with attendance at seminars or webinars that teach cross coding.
  • The best and most thorough method for learning cross coding is through on-site training.

Your last question may be “what dental procedures can we file medically.” In order to file dental procedures medically, you must establish that the dental procedure is medically necessary. Medically necessary procedures are those that are for diagnosis or treatment of a medically necessary dental condition, prevention of a medical condition, improvement of a medical condition, or for rehabilitation of lost skills. Many dental procedures can fall into one or more of these categories. So let’s look at some examples:

  • Any dental procedures performed due to trauma
  • Many dental surgical procedures
  • Sleep apnea appliances
  • Biopsies
  • TMD procedures
  • Perio procedures for patients who are medically compromised by diseases, medical conditions or by medications
  • Procedures performed to provide a dental clearance prior to surgery
  • Medically necessary implants – those that are needed as the result of loss of teeth due to trauma, a medical condition, or a genetic condition; or where bone atrophy has resulted in dentures that won’t seat well, thereby causing difficulties with chewing and getting good nutrition.

Currently, dental sleep apnea treatments that are filed medically are gaining momentum. This is a very strong area for dental practices to pursue. The U.S. Department of Health and Human Services reports that more than 45 million Americans suffer from sleep apnea with eight hundred thousand being diagnosed each year in the USA. Sadly, only 10% are actually being treated. These statistics should be driving a point home – a good number of your patients probably suffer from sleep apnea. With the greater successes in filing these claims medically (including with Medicare), dental sleep apnea procedures could be a very productive addition to your procedure mix.

You can see that there is definitely a need for dental practices to implement this coding system. The need is there and the benefits can be substantial. If you would like more detailed information, please visit my website, www.artofpracticemanagement.com, or give me a call at 252-637-6259. I would love to help you with this important system. You will find that helping them definitely can help you!


Marianne Harper is the CEO of The Art of Practice Management. Her areas of expertise are revenue and collection systems, business office systems, and training dental practices in dental-medical cross coding. Marianne is a well respected consultant, trainer, lecturer, and author. Her published works include “CrossWalking – A Guide Through the Cross Walk of Dental to Medical Coding” and her “Abra-Code-Dabra” series on medical cross coding for sleep apnea, TMD, and trauma procedures. She is also the author of many articles published in dental journals.

EFFICIENCY IN MANAGED GROUP PRACTICE

The future of dental practice is managed group practice.

By Dr. Marc B. Cooper

How can I be so certain when 80 percent of practicing dentists and nearly every other practice management consultant proclaim that solo practice will prevail?

Because context is decisive.
Context is crucial. Context determines the bottom line. Context determines what wins and what loses. For the last 100 years, the context of the dental industry has enabled solo private practice to flourish. But there has been a definite contextual shift and solo practice will not have the wherewithal to be successful as it has in this past.

What causes a shift in context is a series of breakpoint changes in the system generated by breakthroughs and economic demands. For example; the iPhone in cell phones, Southwest in the airline industry, and Amazon in retail shopping. In dentistry, those breakpoint changes are more subtle, but clearly present. Here is partial list of these changes.

  • Emergence of midlevel providers
  • All 3rd parties headed for PPO plans only
  • Over 57% of employed workers having some form of dental plan and growing
  • Dentists graduating with debt of $250,000 and more
  • Seven new dental schools, three of which are for-profit
  • Exponential growth of MSOs/DSOs
  • Loss of state’s authority for dental licensure
  • The Affordable Health Care Act with Exchange Programs and Accountable Care Organizations
  • Less than 20% of graduates seeking ownership
  • 47% of graduates being women
  • Third party consolidation without much antitrust restrictions
  • Vendor acquisitions and consolidation.
  • Emergence of significant private equity and venture capital in the dental space
  • The Comprehensive Dental Plan bill by Senator Sanders
  • Shift of power from Patient-Provider to Purchaser-Payer
  • Rapid and continuous upgrade of dental technologies and costs
  • Drive for measurable and reportable quality assurance
  • Emergence of cloud computing where databases can be examined and analyzed and then algorithms developed for measuring clinical results and access to this data by patients, payers and purchasers
  • Next year, dentistry as an industry will surpass $110 billion in revenues, with a profit margin of almost 18%, attracting large scale investors. Wall Street will be very present.

Managed group practice can adapt to these changes; solo practice cannot. In fact, managed group practice is positioned perfectly to succeed in this new context.
Managed group practice isn’t the same kind of animal as small solo, or two or three partnered practices. Managed group practices are multicellular in nature and, therefore, much more complex. Trying to employ the culture, communications, leadership, management, structures and systems of solo practice in a more complex managed group system won’t work. Therein lies the huge disconnect between dentists currently in private practice and emerging or established managed group practices.

GETTING ON THE SAME PAGE
Many practicing dentists are uncertain about what exactly a managed group practice is. I like to look at it as a species. Let’s take monkeys, for example. A monkey is a primate of the Haplorrhini suborder and simian infraorder, either an Old World monkey or a New World monkey, but excluding apes and humans. Monkeys are generally considered to be intelligent. Unlike apes, monkeys usually have tails. There are about 260 known living species of monkey. Just as there are hundreds of different subspecies of monkeys, there are many different subspecies of managed group practices.

In the species of managed group practice there are small, medium and large ones. They can be a mix of generalists and specialists, generalists alone or specialists only. Some operate within one state, others in regions, some throughout the country, and still others globally in several countries. Some managed group practices are internally managed and they hire executive talent, depending on their size. The larger ones have professional executives such as CEOs, COOs, HR and CFOs. Smaller ones usually utilize existing staff or experienced dental office managers and then outsource some of their executive functions.

Then, there are managed group practices that are externally managed. These entities are called Managed Service Organizations (MSO) or Dental Practice Management Companies (DPMC). They provide all business functions and management of nonprofessional staff. They vary in size; from 8 to 10 offices to 350 to 400 offices. Within the MSO subspecies there are many variations, each offering a unique brand, set of services, and operating contracts. MSOs are typically very specific about the kinds of practices they grow with. I.E. Heartland Dental Care works primarily with single offices whereas American Dental Partners works exclusively with existing large group practices.

In some cases, dentists aggregate together and formalize into a corporate entity called a Dental Service Organization (DSO). A DSO has its own Board and its own executives, but every state mandates that DSOs must be owned and operated by dentists. The DSO is accountable for the diagnosis, treatment planning, and clinical delivery within the group. These DSOs contract with an MSO to provide management services in which case the MSO and DSO are co-joined by a long term agreement. What holds true for DSOs also holds true for those individual practices which are contracted with an MSO.

As most things in business, there are benefits and costs and managed group practice certainly has both.

BENEFITS OF ‘GROUP’
In the world of business everything at some level has a benefit and a cost. For example, hiring a great employee enhances your performance and that’s clearly a benefit, but salaries go up and other employees are affected and that is a cost. There are clearly benefits and costs with managed group practices.

Certainly managed group practice is, by its nature, able to more effectively and efficiently address key issues, concerns and problems that solo practice dentist-owners now face. That is clearly a benefit. The management side of a group practice can generate the executive fire power and staff capacity to deliver business functions, HR functions, more powerful marketing, manage budgets and increase profitability for member dental practices to be more successful than if they took on these functions alone. Here is a partial list of benefits for dentists.

  • Economies of scale
  • Collaboration (We stronger than I)
  • More predictable exit strategy
  • More compelling entrance strategy
  • Negotiation as a group (vendors, labs, support services)
  • Strength in expertise (i.e. HR, finances, marketing, real estate)
  • Quality Assurance can be installed
  • A powerful culture

Here is a partial list of issues that managed group handles far more effectively than individual dentists.

  • Decreasing reimbursement from 3rd parties
  • Increasing government mandates
  • Increasing cost of doing business
  • Regulations and taxes
  • Difficulty in staff recruitment, retention and benefit packages
  • More complex financial management
  • Technology purchases
  • Marketing that really works
  • Negotiating power with suppliers, vendors and 3rd parties
  • Focused customer service

But you can’t have up without down, in without out, so you can’t have benefits without costs.

COSTS OF ‘GROUP’
For the dentist, the costs often seem extremely high.

  • Loss of autonomy
  • Loss of control
  • Loss of decision making in asset management
  • Loss of direct management control with staff
  • Diminished sense of power and authority
  • Loss of the ownership spirit
  • Dealing with executives who don’t understand dentistry

For the management side of the house the costs can also be high;

  • Lack of partnership with dentists
  • Lack of support by dentists
  • Deficiency of responsibility and, therefore, commitment of dentists
  • Absence of leadership by dentists
  • Overriding self-interest of dentists rather than commitment to company’s success
  • Increasing cost of capital
  • Inability to directly manage dentists
  • Immense amount of time required to manage dentists and handle their complaints
  • Dealing with all the internal problems with doctors and staffs that should be handled in each practice location
  • Opposition from dentists in solo practice and their political and legal groups

 

The benefits and costs are easily revealed. But unless the costs are addressed, the ability to institute plans and implement actions for increased efficiencies will be sucked into the black hole caused by these costs.

INTEGRATION
In spite of all the benefits and costs, consolidation is the easy part. What is typically missing in managed group practice, and therefore its greatest risk, is ‘integration.’ By integration I mean the capacity of a managed group practice to develop its dentists to behave and interact like “we” and not “I.” The culture of dentists from dental school through solo practice has always been about “me, I.”

Dentists who join managed group practices rarely develop into a united commitment to the success of the company. Therefore, the company is driven from the top down and consequently struggles to establish a culture that generates a sustainable success. Although being under-capitalized is often cited as the ‘cause’ for the failure of managed group practices, in my view it is the absence of ‘group’ that is the main reason for the collapse of MSOs and DSOs. You simply can’t create a corporate culture, a sense of team, a commitment to company success, and a willingness to change unless that thinking and way of being (I, me, my) are transformed. Is it possible to transform this way of thinking and being in dentists? Yes, but it takes powerful leadership.

LEADERSHIP IS KEY
For many managed group practices this is a big “missing” in their evolution. Treating dentists like employees doesn’t work. Coddling or ignoring them doesn’t work either. Unless there is strong dentist leadership and dentists are involved and on board with a company vision and mission that is bigger than ‘I,’ improving efficiency at the group level will have only limited success.

The fact is, improving efficiencies goes straight to the depth and power of leadership. Leadership needs to generate relationships of trust, a shared vision, high integrity, partnership and a palpable commitment to each other’s success. With this in place, the issues and problems around improving efficiencies can be tackled as a collaborative group and implemented globally with far greater success.

The action of leadership is speaking and leaders speak about a future, in the present. Leaders speak about something that will make a lasting difference and articulate the future in a way people can envision being a part of.

Leaders unconditionally committed to making a vision of the future happen, speaking so others can see it and feel it, get people moving in the same direction. They create a condition of commitment, alignment and attunement. Working inside the new context with strong leadership will set the table for managed group success and group efficiencies that would be otherwise impossible to attain as a solo provider.


Dr. Cooper’s professional career includes private periodontist, academician, researcher, teacher, practice management consultant, corporate consultant, trainer, seminar director, board director, author, entrepreneur and inventor.

Dr. Cooper has studied with masters in many disciples, participated in formal business educational programs, and worked as an independent contractor with top-flight consulting companies. In 2011, Dr. Cooper was selected as a coach for the prestigious TED Fellows Program.

The Mastery Company has been in existence since 1984. Dr. Cooper’s client experience in dentistry includes solo private practice, small partnered practices, managed group practices and retail corporate enterprises. Dr. Cooper has worked with numbers of health care entities such as insurance companies, clearing houses, bio-technical companies and disease management companies, as well as the senior executives and boards of large hospitals and hospital systems and a number of their related physician groups. In addition, Dr. Cooper has worked with Silicon Valley start-ups and Fortune 500 companies and he has worked with dental clients internationally.
Dr. Cooper has written seven books including; Mastering the Business of Practice, Partnerships in Dental Practice and Running on Empty to name a few. Subscribe to his newsletter at www.themasterycompany.com. Dr. Cooper can be contacted at: info@masterycompany.com

Electronic Dental Records and the Efficient Group Practice

By Mike Uretz

Operational Standardization
While helping a number of multi-clinic, multi-specialty groups acquire and implement electronic health records over the past few years. I have always made a point to find out the reasons why these large groups opted to integrate electronic records as part of their IT strategies.

There are a number of reasons both financial and clinical, but one reason that I hear consistently from group practice CEOs and COOs is that with the numerous providers and clinics in the organization, it is important to try to standardize on various parts of their operations; with none more important than clinical data. So with that goal in mind, where does a group dental practice start?

The first step would be to develop and utilize an internal clinical advisory committee. In this way, the Electronic Dental Records and its associated templates can be designed to standardize the way the clinical team treats patients.

Whether it is evidence-based procedures, patient education, or the use of treatment protocols, having an agreed to, consistent clinical strategy can be established and supported by the use of EDR technology within the group practice organization.

With a flexible EDR system in a large organization, even if certain clinicians wish to tweak their templates to match their particular way of providing care, at least it is possible for all the care between clinicians and the group practice locations to at least have vital elements in common.

A sophisticated group practice will develop libraries of templates, protocols, and treatment plans that can be reused by each dental team member without reinventing the wheel each time they need to create a document or ensure they are adhering to standards and procedures, mandated by corporate, insurance companies or government agencies.

Clinical Consistency
Another important reason to standardize on EDR within a group practice organization, especially in a multi-specialty environment, is that each clinician that touches the patient (GP dentist, periodontist, endodontist, etc.) has the same clinical data and medical history to refer to.

For example, past procedures, medications, systemic health history, and other critical bits of clinical information are available in real time at the fingertips of each member of the collaborating dental care team. Too often in a multi-practice organization, it is easy to not have critical information readily available if the patient travels between group practices locations. Or, even more common, as the dental clinician rotates between different practice locations.

From a CEO’s standpoint, a good EDR system can also hold their clinical staff accountable for providing optimal patient care. Through detailed and standardized reports and analysis, a group practice organization can know how where their clinicians stand regarding patient outcomes and whether or not they are following standard protocols.

For example, something as simple as providing listings of which dental team members have reviewed and signed off on their notes and which notes in the organization were still unsigned, can be a powerful tool for raising the standard of care and in some cases, reducing legal liability.

As a whole, the organization can use benchmarking data and see how one practice is performing in terms of patient outcomes and through-put care versus other practice locations.

In a large multiple practice organization, those patients needing additional care and recalls, can often get lost in the shuffle with a manual records system. With an EDR system there can be more revenue generated as well as better patient care by automating appropriate clinical alerts, recalls and regularly scheduled hygiene appointments.

Finally, a group practice with multiple offices can have better cash flow by utilizing EDR. That’s because, automated coding at the point of care can seamlessly flow through to the claims processing system reducing the need for a lot of manual intervention.

EDR Purchasing Guidelines for Group Practices
Although there are some similarities from a clinical standpoint when evaluating EDR for a group practice compared to an individual practice, there are a number of specific concerns that are specific to a multi-location group practice.

One of the biggest differences is in the areas of technology and support. Having been involved with IT for over 30 years, I am always concerned when a multi-practice group adopts EDR technology, because there are numerous technical items to evaluate that a small private practice doesn’t usually need to address.

Future-Proofing Your Group Practice EDR System
For example, the ability to aggregate, process, reconcile and report on data sourced from multiple practices puts a highly-increased level of complexity on the software that isn’t found in every EDR system. So, questions must be asked surrounding communications, interoperability and aggregation of data between multiple practices and the “scalability” or expandability of the EDR software that you are evaluating.

Finally, the scalability or ability to expand the database to anticipate and meet future needs is extremely important in a group practice or IT environment. Because of the sheer number of records that will be imported into the system over time, it is important to make sure that all the technology you are purchasing with your EDR is “scalable” or expandable.

As we discussed previously, another feature that would be essential when you’re talking about a group practice organization is the ability to produce common libraries of templates, protocols and treatment plans that can be used throughout the organization.

Ways to Save Money on EDR Support and Training
Because a group practices will typically have either an IT person or department, it is critical to make sure that the technology that the EDR system is built on is compatible with the technology that is currently being used throughout your organization.

One common mistake I’ve seen in the medical field is to purchase an EHR system that was based on a proprietary technology, especially for the database, which would prevent the organization’s IT folks from easily accessing or working with the data.

The customer support model in a group practice can also be a big deal when contracting for EDR software. In many cases, if the group practice organization is willing to provide “first level support” for the software, then the software vendor might be willing to reduce your yearly support maintenance costs.

First level support can be as simple as any issue that is found with the EDR system first goes to the IT department to triage with the vendor instead of the user contacting the vendor directly. Again, with a group practice because there is typically IT support within the organization, it is worthwhile to evaluate whether or not costs can be reduced by utilizing this resource.

Also, from a cost standpoint, recognize that with a growing multi-practice group there’s a good chance that over a period of time you’ll add practices and clinicians to the mix. So, when negotiating your deal for EDR it’s important that you put some kind of price freeze for a period of time, so that you can purchase licenses and services at the same discounted amount as you grow the organization.

With a group practice there is also more of an opportunity for the vendor to do some nickel and diming after you purchase your system. This is based on the fact that with a multi-practice organization there will probably be more opportunity for various interfaces and inter-practice communications that if not addressed in the initial proposals, could potentially add considerably to the cost of the system after the fact.

With implementation and training of a larger group practice there is also an opportunity to save additional costs by using what is known as the “Train the Trainer” approach. With an individual practice,, typically the vendor will train each staff person individually depending on their roles.
However, in a larger group practice environment there can be multiple people in similar roles. So the best and most cost-effective way to accomplish training in an environment like this is to designate a few people as the EDR experts in the group practice who will be trained by the vendor.

In turn, the internal EDR experts are responsible training additional staff within the group practice. This saves money in two ways: First, it takes less time for the vendor to train a smaller group of professionals, so that saves money. And, once your internal people are trained and can train additional dental team members, then there is no need to call upon the vendor and be charged each time a new person comes on board.

Closing the Meaningful Use Loophole
What’s more, with the growth of meaningful use and electronic records, if you have a number of clinicians and if you do have a good percentage of Medicaid reimbursement, then your group practice organization can stand to recognize a fair amount of reimbursement provided you utilize a ‘Meaningful Use Certified” EDR system. At up to $67,000 per clinical provider of reimbursement if you have multiple providers this can certainly add up.

If you do decide to go the route of the meaningful use certified EDR system, make sure that contractually your software vendor makes the appropriate commitments to continue to support meaningful use. I have seen too many contracts where “Meaningful Use” warranties had no teeth (no pun intended) should the vendor fail to provide eligibility for their customer.

Finally, if you are a multi-practice group with a number of in-house specialists , having the ability to interface with a health information exchange can foster referrals from other GP practices that also have electronic records systems.

Features such as the ability to interface with an HIE (health information exchange) are typically lost in the shuffle. The onus is typically on you as an organization to bring up whether these capabilities are available in the EDR system you are evaluating.

If a software vendor does tell you that their EDR system does provide interoperability with other systems and technologies, then make sure they either give you a demonstration or give you specifics on how this works… And a guarantee to the fact when you decide to purchase.


Mike Uretz is a 30-year healthcare technology veteran and nationally-recognized electronic health records (EHR) and healthcare software expert. As Executive Director of the EHR Group, Mike has consulted hundreds of individual practices and larger multi-clinic groups to help them properly evaluate and select their EHR solutions, structure and negotiate contracts, and provide management and oversight for their implementations. In addition, Mike has been a member of the Certification

Commission for Health Information Technology (CCHIT) EHR vendor certification work group, and has helped a number of statewide Regional Extension Centers, under the Federal Meaningful Use Incentive Program acquire EHR technology. As co-chairman of the National Regional Extension Center Program’s best practices advisory committee for EHR Contracts, Mike has been instrumental in developing standards for structuring vendor contracts and pricing for use by state programs nationwide
Mike is now applying his wealth of knowledge and experience to the dental industry, including group practice owners, to consult them on dental EHR software best practices, and to help them avoid the pitfalls experienced by other healthcare professionals.

Mike is also the founder and editorial director of DentalSoftwareAdvisor.com a trusted, an objective online resource on all matters related to dental software. Mike can be contacted at MikeU@DentalSoftwareAdvisor.com or 425-434-7102.

Competition is What You Make Of It

By Ben Burris, DDS, MDS

If you don’t have a competitive edge, don’t compete!

If we follow this FIRST RULE and are sure our business, our model, our product, our target demographic and our marketing are what and where they should be before we begin, then life is easier and competition becomes irrelevant.

Whether this means having the best product, most desirable product, coolest product (these are not synonymous), being in an underserved area, having the best customer service, the least expensive product, the most convenient location or just being an overall dominating force that does everything just a little better than anyone else, we must have an edge. We must also be aware of exactly what we do and who we are that gives us our advantage:

Who is our target demographic for 1) patients and 2) decision makers? What is our model? What image do we portray? How are we perceived? Who are our referral sources? (specialists, moms, school teachers, other businesses…). This list is not all inclusive but we must all, in our own way, have clarity about what we do well, who recognizes what we do well, who is willing to send patients our way and why this is the case. We must have a clear self-image, know why we get the results we get, know what we do well and stick to our strengths. This is not to say that one cannot or should not change. We certainly can and sometimes should alter even the core of who we and our businesses are, but this MUST be a conscious decision and not one that occurs due to neglect, arrogance or “creep” over time.

In practical terms, if what we are doing is working, great. We should be very careful about altering anything out of boredom or venturing into unexplored areas because of overconfidence derived from our success in our core business. Better to grow what we have and repeat our proven business model, modifying and purifying it only to enhance what we do to adapt to changes in the landscape or technology. It’s tempting to apply one’s success to other ventures outside our areas of expertise, but the odds are stacked against us. We have all heard the stories about successful practitioners who start other business ventures and we know what the usual result is. Stick to what you know!

If you want to expand then expand your capacity. You are a problem solver and solving more problems for more people means you will be paid more. First, maximize what you already have and thereby reduce the percentage your fixed overhead costs consume. Increasing efficiency during current office hours, maximizing production, expanding office hours, increasing the number of days worked in an office, increasing marketing to produce more new patients to feed the enhanced capacity, additional staffing within reason, new technology, incorporating other specialties and expanding services offered, increased speed through continuing education and practice. Only after all of these avenues to more production are maxed out should one expand one’s footprint and add to the fixed overhead. New offices and multiple locations are glamorous and can be effective but unless you have unlimited funding, maximizing the potential of current facilities is a must before expanding. You can work less and keep more if you take care of first things first!

Of course, for many of us either a lack of capacity or the desire to expand eventually wins out and we have multiple locations. That’s what Efficiency in Group Practice is all about so I’m not saying you shouldn’t expand! I have just learned the hard way that it is much more pleasant to expand once you’re on firm financial ground and by self-financing if possible.

We also need our systems to be well honed before we try to replicate them. If we are not getting the results we want, then we do not have the luxury of resting on our laurels while making minor course corrections. In-depth self-examination is necessary. In fact, we may not be capable of having the objective view we need to elicit real change ourselves; the situation may call for the assistance of a third party. Once you decide that it’s time to figure out where you are, what you’re doing and why it is not producing the results you want or need, it will take strength, courage and force of will to recognize what must be done to achieve your desired outcome. And be prepared that it may take massive effort. If we have an objective assessment of our condition, rarely will we find that the “competition” in and of itself is responsible for our shortcomings. It is almost always our level of care and service RELATIVE to the competition. We cannot change the other guy so that narrows down our options considerably! On the rare occasion that “too much competition” is the culprit and cannot be overcome, then we must decide to either live with things the way they are or move. Neither is very appealing so I encourage you to decide that competition is not the reason for your woe! Realize that you have the power to change you and DECIDE that changing, along with all that pain and fear, is preferable to underperforming. You can do it and will be amazed by what you can accomplish once you set your mind to it! There is a plethora of consultants, advisors and especially successful peers who are happy to help you succeed. All you have to do is ASK, LISTEN and IMPLEMENT.
Competition is good. Competition drives innovation. Competition improves access to care and efficiency. Competing effectively is what you did to get into and through school. We all have the ability and it is simply whether or not we have the desire and will to make the tough choices or stay the course as appropriate. Of course, we need enlightened self-awareness to know what to do before we act! Competition is what you make of it because ultimately, it is all about you. YOU choose where to go to school. YOU choose how much money to borrow during school. YOU choose where to practice. YOU choose how to run your practice, interact with your team and the community, how hard you work, how smart you work. You choose how large your practice will become and how many locations you have. All of the titans of corporate dentistry started out small at one point or another and then leveraged what they did well to grow to what they are now. You can do it too – should you choose to.
I love to rationalize, but I know deep down that all my failures are my fault. The good news is that by adopting this mindset I get to take credit for all my successes, too, and I NEVER HAVE TO BE A VICTIM. It’s all my fault. I got myself where I find myself today and therefore I have the power to change the situation should I deem it necessary. It may sound strange but we must accept all the blame — for every aspect of our lives — to attain true freedom!

You cannot affect your competition by focusing your energy on him or her. You can, however, change by doing what you do extremely well in a clearly defined space and with a crystal-clear mission. Competition is good. Change is good. We welcome it and hope you do as well. If you don’t it may be time to examine your model, your location, your motivations or all of the above.