The Business End of Hygiene

Asking tough questions can improve production

Ann-Marie DePalma, CDA, RDH, MEd

As hygienists, we are charged with educating patients regarding their health or disease. Using the appropriate codes and documenting what we do is our ethical and legal responsibility. Yet we are a business within a business. Practices grow or wither based on hygiene production. Practice management consultants estimate that 40% - 60% of restorative treatment comes from the dental hygiene chair. Is your practice healthy enough to support that scenario? Do you know how you are affecting the total practice business, both positively and negatively? While many teams and practices discuss their goals, others do not. What type of practice do you want to be associated with - one that is simply surviving or one that is flourishing? Determining how the practice is moving forward requires asking some direct questions of yourself and your team.

Do you have enough time to educate and treat patients appropriately? Years ago it was believed that the more patients seen in a day, the greater the production and receivables. Hygiene was considered the "loss leader," and many practices still believe that is the case. Yet today's dental patients are savvy consumers: They know when appointments are rushed and are demanding more from their health care providers. The dental benefit insurance landscape has evolved in a way that many practices have to accept huge write-offs to participate in plans. Even though you may be seeing the same number of (or even more) patients, the amount the practice collects is much less due to the write-offs. So what is the hygienist to do?

For example, have you or other team members done a procedure analysis to determine the actual time needed for patient care? A procedure analysis is a timed process of reviewing how long it really takes to perform a procedure. For example, a hygiene procedure analysis would begin from the moment the hygienist takes the patient from the reception area, through initial review of information, to treatment (including charting, scaling, imaging, and education), to doctor evaluation, to business team handoff, and to final breakdown and set up of operatory. This analysis can be done over a certain period with a variety of patients and procedures. Then an average is taken and the appropriate time determined.

Do you have enough time to do all that today's hygiene practice demands? If not, what is missing? Most often it is the educational piece - not just brushing/flossing but talking about disease or health, including discussing appropriate health findings. It is well known in practice management consulting that the more time taken with patients, the higher their case acceptance. What is the practice case acceptance rate in your office? Do patients say "yes" at the moment and then cancel the day of treatment? Your office may want to rethink the amount of time for appointments and patient care, based on outcomes of the procedure analysis and case acceptance rate.

Is the practice using correct and current coding? It is the hygienist's responsibility to code what was done. Even though business team members are the experts in the practice regarding billing and coding, the clinical team determines the treatment provided for the patient. If the patient presents with generalized bleeding and inflammation with no bone loss, is the appropriate D4346 code being utilized? Many practices are afraid to use the code, since "insurance doesn't cover" the treatment, and they don't want to upset the patient with a greater out-of-pocket expense. Yet it is not the practice's responsibility to know what the patient's benefit is - it is the clinician's responsibility to code what was done. To do anything less can create a number of problems. A practice utilizing outdated codes for some procedures may be losing out on revenue, not to mention the time it takes for business team members to resubmit claims.

Is the practice management software utilizing the most up-to-date ADA CDT code? Does the practice know how the system updates to the correct codes? As dentistry moves to a more medical model of coding in which diagnosis is part of the treatment coding process, using the most current, accurate CDT codes and documenting appropriately is going to become critical to the overall health of the practice. Hygienists should understand and initiate educating the team on appropriate use of hygiene-related codes.

Are you aware of the new periodontal classification system? In 1999, the American Academy of Periodontology (AAP) issued "new" guidelines for periodontal disease, and dentistry and dental hygiene have been using those guidelines since then. In 2017 at the World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions, the AAP and the European Federation of Periodontology (EFP) released an updated classification of periodontal and implant diseases that focuses on staging and grading of the disease process, similar to medicine's staging and grading of disease. Although not widely used yet, over the next few years this documentation of periodontal disease or health will become the norm. Educating yourself and the team about these changing criteria will benefit patients and the practice.

Is the practice utilizing its practice management software appropriately? Is the most current up-to-date version being used? As a hygienist, do you know the backup and testing protocols? All of these have implications for the practice from a business aspect, whether through obtaining the correct data or experiencing lost revenue from hardware or software down time. What would you as a hygienist do if the system crashed? Computer failures are a fact of life in today's technology-driven business environment. Is there a plan within the practice to keep the business going if a failure happens, and do you know the practice's protocols?

In addition, has the team had training on the software's latest features? Technology and its constant upgrades require that users be attuned to changes that occur in order to use it to the benefit of patients and the practice. When was the last time the software was updated, and training for team members occurred? Can you obtain information about your production, collection, and service mix through the software?

As hygienists, the business end of our clinical daily practice is not something we often consider. In order to provide patients with the best care - and the practice with profitability - hygienists need to understand and review their practice protocols, asking these and other tough questions.