The American Dental Association has tried to help all of us during this pandemic, and they have done a fantastic job. Yet, so many of you have slapped them in the face because of your ignorance in business. Believe me when I say I’m one of the first to call out the ADA when they do dumb things, but many of you have exceeded the dental insurance companies’ expectations of stupidity, and they know it.
It was 1985, the letter came, I was accepted to UOP School of Dentistry. I was to report for the first day of school in July 1986. I had recently gone in for a dental cleaning where my dentist, and his team, were not practicing “universal precautions.” UOP School of Dentistry was transitioning their students to wearing gloves, masks, and eye wear prior to the start of my class.
With the AIDS epidemic, pandemic, disability (HIV descriptions carried many identifying categories back then) OSHA was proposing guidelines from the CDC, methods to reduce healthcare workers’ exposure to bloodborne pathogens, such as HIV and Hepatitis B. These guidelines embraced the concept of “universal precautions” to protect against exposure to blood and other body fluids. The CDC noted in dental settings, saliva should be considered a hazardous body fluid because it is likely to be contaminated with blood during typical dental procedures.
What most of us don’t know is the fact, at that time, many dentists were against such “universal precautions.” They stated that it would affect their doctor-patient relationship, creating an unfriendly barrier when caring for their patients, especially children. In addition, there were no known transmissions of AIDS or Hepatitis B in the dental setting. The ADA was actually leading the charge against OSHA’s bloodborne pathogens rule. The ADA argued, among other things, that there was little evidence to show that dentists or hygienists were at risk of exposure to bloodborne pathogens. The ADA went on to argue that dentists could decide for themselves and for their employees if, or when, gloves, masks, and eye protection should be worn. Dentists simply did not need the government telling them how to run their businesses, and they did not need to be burdened with the costs associated with “universal precautions.”
When the rule was finalized in December 1991, the ADA exercised their right under the OSH Act to challenge the rule before the U.S. Court of Appeals. The court didn’t buy their arguments, and in January 1993, the OSHA rule was upheld and would apply to dental practices. Dentists would need to adhere to “universal precautions” and figure out a way to recoup these costs of governmental regulations.
What costs were dentists facing from the mid 80’s and moving forward? Dentists were looking at five cents per glove, fifty cents per mask, and generally a one-time-fee for protective eye wear. Many dentists didn’t think twice about bundling those costs of goods, because they could just increase their fee-for-service fees a few dollars to offset those costs. However, those were not the only costs, those were just the “talking points” because they were the most visible. What dental offices were also hit with was disinfection protocols that increased not only costs of goods, but also direct operating costs of time taken to adequately wipe down the operatory between each patient visit. Oops, something most dentists never take into account when running their business.
The ADA was cognizant of the new financial burden placed on dental practices, and therefore created the code D1450: OSHA Fees for dentists to use with each patient. This code was used in the 1990’s, it employed an average fee of $5 per patient per visit, and was actually covered by most insurances. That was until the dental insurance companies lobbied the ADA to simply remove the code from the system. That’s correct, you won’t find that code in the ADA’s CDT Code Book anymore. However, many of our insurance contacts here at MPMB remember the code. Many of those insurance reps actually worked for dentists during those years, and they remember billing the code D1450. As insurance companies became publicly traded, they soon learned they needed to look at their bottom line for their shareholders. Just like with other codes we use to have, codes we use to be able to charge for, dental insurance companies began to flex their muscles. They argued dentists should just “bundle” the D1450 OSHA fee into their cost of doing business. Does this not sound familiar? The unfortunate truth is that dentists just rolled over and accepted this ludicrous business concept. Why? Because of our lack of business training. More on this later.
Now we fast forward to the lovely pandemic year of 2020. With the introduction of SARS-CoV-2, the novel coronavirus that causes coronavirus disease in 2019, which we all now call Covid-19, our costs of doing business are again on the rise. I want to clearly point out, as of the writing of this topic, OSHA and the CDC have both referred all dentists to their State Health Departments for guidelines pertaining to additional infection control protocols going forward during this pandemic. To date, there are none, zero, zip rules, mandates, regulations, or requirements when it comes to additional infection control protocols for dental offices in most states. There are only recommendations and suggestions, and many of them are without data as to their efficacy in preventing the transmission of airborne pathogens, more specifically, Covid-19. In addition, all the State Health Department Heads have commented on how well dentistry has implemented universal precautions from the 1990’s to date. They all seemed to complement our profession with our infection control protocols we currently use. Take that for what it’s worth.
With all that said, most dental offices have taken their infection control protocols to a new level in varying degrees, based upon, what we are seeing, their locations in the country, and the recommendations their State Departments of Health are giving, especially those suggestions that make sense with the data we currently have. One thing is certain, dentists are acquiring new costs of goods which are affecting their direct operating costs of doing business, and the ADA has done an amazing job in recognizing these additional costs.
So, what has the ADA done on our behalf during these troubling times? They went to battle for us with the dental insurance companies, in attempting to get them to, once again like back in the 1990’s, offset our costs of goods by covering “personal protective equipment” under the CDT Code D1999. It’s right here where I want to just reach through my podcasting microphone, or reach through my published book, look you directly in the eyes, and ask the proverbial question: “what in the hell is wrong with you?” I’m going to address all of you with what is called, “hard things,” when it comes to the business ineptness of the majority of dentists, and their self-appointed office manager experts in the field of dentistry. I hope my words shake all of you to your business core, and cause you to dismantle ignorance and complacency in your practice, and maybe beyond. Here we go!
I have yet to find one of you who are happy with your reimbursement rates from the dental insurance companies you have contracted with. You consistently complain, and rightfully so, about what these dental insurance companies are doing to the practice of dentistry, and more specifically, your own practice. You complain how PPO plans and EOB verbiage are destroying the doctor-patient relationship on a daily basis. The ADA engaged several years ago to get dental insurance companies to stop that non-sense verbiage, but they have not been as effective on that battle as they would like to have been. However, here the ADA is trying to get us reimbursement for the additional PPE costs of goods, going to battle with the dental insurance companies, and here are the comments we are seeing across the country. It gives me consternation just bringing up what I’m about to, but it merits making examples of what is out there on the social media outlets. Let’s begin:
Here was the question that started the facade covering avarice of crap:
“Is everyone charging for PPE under D1999 like the ADA has suggested? If so, what are you charging?”
Great question, one that should never be asked if you actually understood that your primary job is profits and profitability. It’s a question that would not be asked by most with an MBA and practical experience. But I get it. Very few understand what I’m communicating here, and it’s a valid question. It’s not the question that concerns me as much is it is the answers that came her way…Here we go!
“Isn’t everything we do the cost of doing business? Cleanings, fillings, crowns, etc. are all the costs of doing business and we charge the patients for it. When lab costs, supply costs, etc. go up, fees go up. That’s how businesses work. We chose not to add a specific PPE fee because we don’t also have an autoclave fee or a ‘we wiped your room’ fee because those things are the cost of doing business. My doctor evaluated our costs and our fees and did a small increase. We have had no complaints. A couple of patients have said ‘that is more than last time’ and I say yes. Your last visit was x dollars and this time it’s a few dollars more. No big deal.”
Obviously, this OM hasn’t lived long enough to be in dentistry when we had the D1450 OSHA code as I explained earlier. I’m not against raising fees to cover costs of goods if your entire practice is fee-for-service, but I’m more in favor of being completely transparent with our patients and creating or using an existing code that states such. Again, when we have the opportunity to use a code to define what we do, especially when the ADA is trying to have our back, let’s use it. I like that she told the patient she is correct, it’s a bit more, no big deal. That’s how we should approach it.
“Just raise your prophy’s and periodic exams by three dollars then they are unaware of PPE charge.”
Again, where is the transparency in this protocol?
“PPE must be the gift you give your patients to say thank you we value your loyalty.”
You’re fired! How about you work for your doctor for free one day a week as a gift to him or her. This is the typical OM that undoubtedly has never taken a business class, and if they did, they didn’t pay attention. Un-freaking-believable!
“Our office thought about charging for PPE. We are in network with a few insurances and when the first one stated ‘not billable to the patient,’ I stopped the inquiries. It would not be fair to bill, unless it is across the board to all patients. Please check your contracts if you are in network.”
She showed Delta Dental’s letter that stated dental offices were not permitted to charge their clients for PPE, OSHA, or infection control. Well my goodness gracious, if one PPO plan says “no” we should allow that insurance company to dictate all of our financial protocols. Not only is that a terrible decision, it also indicates this OM’s inability to find opportunity instead of obstacles. Little does she know that no insurance company, especially Delta Dental, can prevent you from charging your patient directly for PPE, if you know how. At MPMB, we know the rules, and we know how it can be done. But if you don’t know how to pursue the truth, like business rules and regulations with dental insurance companies as they relate to your State, you just don’t know what you don’t know. Do you want to be an office manager or an office assistant? We turn front office team members into office managers all the time through our training.
“It all seems so justifiable and easy. Believe me, not all your patients are going to say sure, no problem, I’ll pay the extra cost. To us, our patients have been through enough, and charging PPE was not worth losing several patients over it. Some were getting pretty upset. I’m happy our doctors made the right decision for us not to charge any extra for PPE. Every office will hopefully make the right decision for them or have some pretty upset patients.”
Well, my OM friend, it is easy, and justifiable. We train our offices to ask the triage questions the ADA put out for us to ask prior to their appointment, and at that time we let them know there will be a small fee for additional protocols we have had to implement. ALL of them have understood, have not been upset, and have thanked us for keeping them safe. We haven’t lost one patient over it. What a business concept. It’s all in the verbiage. Did your doctors make the “right” decision? Heck no! Why do most offices allow the few to rule the many? A few patients get upset, and the OM pushes the panic button, huff and puffs to the doctor, and the doctor caves. I’ve seen it for too many years. One OM actually echoed what I just stated in the OM networking group, and she nailed it! Only to be slammed by so many others who simply do not have the commensurate training or expertise. Go figure.
“Charging a PPE fee maybe standard in the future, but to hit patients with this as soon as they return to the office may have an undesired effect.”
Well, when in the future would be a good time to charge the patient for PPE? Aren’t you incurring costs of goods on day one? Another lack of business training.
“Run a report of the most frequently performed procedures. Take the top five and raise the fees 2-5%. Then you cover your additional expenses and no one has to be notified of anything. If you are in network, be sure to include some of your top procedures NOT covered at 100%.”
Let’s place the cost burden on a portion of your patients for all of your patients. And how are you planning on your insured patients paying on procedures that have assigned CDT Codes in your contract? That would definitely be a breach of contract. Oops. This out-of-box thinking is a start, but it should stay in the box.
Comments Eight and Nine:
“We are billing it out to the insurance, but if the insurance denies, we’re writing it off.” Followed by, “we are too.”
Those OM’s are my favorite. To which I tell them if we have a billable code, but the insurance company decides not to cover it, or they don’t pay their full portion, and you arbitrarily decide to write it off instead of collect from the person responsible for paying the bill, like the actual patient, then I’m deducting that amount from your paycheck, instead of you deducting it from mine. Duh. Need I say more? This reminds me of the OM who told me in an introductory training that they give away dentistry as a courtesy to their patients. I simply asked if she had a degree in business, any degree, associates on up to a masters. She replied she has her degree from OTJ University. I told her to keep plugging, the first week is always the hardest. She didn’t get it.
“I hate to tell you, but most dental offices have been practicing OSHA guidelines and have been using PPE for years. I don’t understand the increase in fees.”
It’s called an increase in cost of goods. It was a billable code years ago, get over it and charge for it.
“Visually people struggle with one more thing to pay for.”
Learn how to place oral health care at the forefront of their discretionary funds. Consumers buy all kinds of junk, the struggle is in your head, not so much theirs.
“You’ll lose patients over $10 because let’s be honest, we all know there are some people so picky about spending what insurance won’t cover. Is it worth losing patients over $10? I believe it’s a part of overhead. Crazy expensive, but part of owning a dental practice. I like the idea of cutting costs elsewhere!”
Let’s be honest, you’ve trained your patients for years to be treated to what the insurance covers only. And your last comment is spoken like someone who has never owned a dental practice. The only cost cutting if you worked for me would be your termination.
“Share costs between the patient, insurance, doctor, and the business. We are in this together.”
I was at the grocery store and at check-out I told them that my total bill needed to be shared between me, the store, the City, the State, and you register person. It didn’t go over well. Nothing like seeing socialism rare it’s ugly head right there in the dental practice.
“We would never charge our patients for PPE, if you’re looking to lose patients this is the way. That’s working for a cheap doctor who just wants more money.”
How insulting. Do you really think so little of dentists when they simply want to be paid fairly for what they do? Don’t you want to be paid fairly for what you do? Cheap office managers typically breed cheap doctors. A doctor who wants to charge fairly for his or her services is a doctor who understands the clinical business of dentistry. I would want to work for them.
Comment Fifteen and beyond:
“So wrong to charge. How much can it possibly be costing you? Add $1 to all services if you really need the money.”
“The uninsured patients are paying for the PPO patients.”
“We’re cutting expenses instead of charging for PPE.”
“We’re not giving away toothbrushes anymore to cover PPE.”
“There are tons of ways to cut the fat without directly asking for dollars from our patients.”
“If your practice is looking to lose money, charging for PPE is the way. It’s not cheap, but it’s just the economics of doing business. Don’t charge!”
“Yeah don’t charge them…it’s not their fault. WE are not charging that’s just ridiculous!”
“Infection control fees were charged in the 90’s with HIV appearing. Was not popular then either.”
“Yes, don’t charge.”
“It’s a marketing death sentence to charge your patients for the PPE. WE thought about it and after hearing so many stories about unhappy patients we are glad we didn’t follow through.”
As Tracy was reading these posts to me on our way to work, my blood was boiling. All of these office managers, and the doctors they serve, would receive a big fat freaking “F” with their business logic in any MBA program in the U.S. of A. It’s time for you to change your thinking Doc, so that you can lead others in your office, more specifically your office manager, into more sound business decisions and protocols. Is there any wonder why corporate dentistry, as bad as they are in many cases, can thrive in our profession? They get business. However, with a little bit of business training, my solo practicing friends grow, profit, and thrive too.
Not all posts in the office manager networking group were business ignorant. This comment helped my blood return to near normal temperature. “We figured out that the extra PPE will cost our office over $50K for the remainder of this year if the prices stay as they are. We went above and beyond what is being recommended. I’ve had very few people push back. When the couple that did question it we simply explained that this will cost the office the anticipated $50K and we are asking the patient to help with some of the costs. We also explained that most businesses are passing some of this fee on the customer. Once we explained it, not one person pushed back again. On a joking matter, when I told my husband about one patient that did, he replied, you could always offer to use less PPE.” That’s funny!
Don’t think for one-minute dental insurance companies don’t look at these posts and make policy decisions off of them. When they see this kind of crap from social media, they know they can more fully walk all over us. Why do all of you insist on feeding their business narratives? Why do you insist on slapping the ADA in the face when they attempt to help you increase your reimbursements and profitability?
You are reaping exactly what you sow, and you deserve everything you get with the ridiculous business thought-leadership you have displayed this year, and each and every year you empower your status-quo. After listening to this podcast, or reading my book, you no longer have the excuse of “we don’t know what we don’t know.” Don’t you complain to me, the American Dental Association, or anyone else about your reimbursement rates, and the fact that your income is deteriorating. As for all office managers, and other team members, reading or listening today, your false narrative badges of honor have been exposed, and you certainly do not deserve a raise, bonus, or any other compensation, as you have not understood your primary job responsibility, and that is profits and profitability.
The next time I hear a dentist, office manager, or any team member complain about the ADA, dental insurance companies, or the difficulty in running a profitable dental practice, you know the question I’m going to lead with… And in the back of my mind will be my profiling thought leadership…and how you doc, have enabled this mess, and how you honestly deserve exactly what you are complaining about if your thought leadership has been anywhere close to what has been discussed today. If you feel I have presented hard things for you to swallow, then good! Maybe you need to choke on them for a while until you more fully begin to understand the clinical business of dentistry.