These two terms are not necessarily mutually exclusive. I have seen ample evidence that a practice can be large, very large in fact, and still produce high quality dentistry or orthodontics while maintaining a wonderful quality of life within the practice.

  For this essay, the definition of the word "quality" does not refer to the quality of the clinical product but rather to the quality of life within the practice for the doctor, for the staff, and for the patients. The question is, "How does the philosophy, 'growth at any cost', impact the practice and the quality of life within the practice?"

  No doctor I know, or have ever heard of, will actually admit to the philosophy of "growth at any cost." However, the decisions made and actions taken within the practice demonstrate that many doctors are willing to give up quality of life in order to obtain a larger gross.

  During the past years I have had significant, sometimes heated, conversations with doctors of every type and specialty, including a number of our own clients. These doctors had chosen to abandon reasonable (from my point of view) financial and marketing policies in an effort to attract ever greater numbers of new patient exams, and to generate ever greater numbers of case starts. Some doctors signed up with MSO's, in spite of the tremendous long term cost, simply because they were promised growth. Others signed up with the various forms of Managed Care (PPO's, DMO's, etc.). Others took out Yellow Page advertisements, did direct mail advertising, etc. One southern California client put up a freeway billboard and another signed up for "1 800 DENTIST"!!

  These doctors would not look at the fact that their new marketing was attracting heavy numbers of extremely low quality patients. They would not look at the fact that their policy of starting these patients into treatment, often with token down payments and long-term financial arrangements would render the patients uncontrollable. They did not recognize the significance of the fact that although they only have 6 employees, they had 10 W-2's to mail out at the end of the year. Some even wondered why I thought that was a problem!

  One orthodontic client, a doctor who we had successfully weaned from participating with five separate Managed Care organizations, panicked when he realized that his total new patient flow and total case starts for the year were less than in the previous year. He did not consider that in spite of 15% fewer starts, he was producing and collecting 22% more revenue, his net had dramatically increased, and his rate of failed appointments, emergencies, and incidents of poor clinical cooperation were all much improved. He did not consider that his clinical and administrative staff was much happier. He cared about one thing and one thing only, how "big" his practice was and he measured "big" by the number of total case starts.

  At a recent trade show meeting, a well-respected and nationally known doctor was lecturing. He made a comment that many doctors consider heretical. He said, and I hope he will excuse my paraphrase

of his actual statement, that it is not only acceptable but is desirable to restrict new patient flow and to restrict the rate of case acceptance in order to ensure that the practice only examines and starts the quality of patient that the practice wants to see. He said that his quality of life within the practice was more important to him than going after every last possible case start. Interestingly though, that commitment to quality patients and quality starts often generates growth and practice size beyond that which most doctors could otherwise attain.

  The foundation or core of our consultation and the entire credit management system we teach our clients is based on the assumption that the practice commitment to quality of life will take precedence over "growth at any cost." I have been consulting for more than 21 years and have personally been in more than 750 client offices. We have clients at $33,000 per month and we have clients at $400,000 per month. One thing I have learned and learned well is that the doctors who are able to sustain their practices year after year, with the same staff, with a great net income, with happy patients, with an ever increasing number of new patients referred by existing patients, have been those who were committed to growth, but not at the expense of the practice quality of life. Every decision made concerning the practice, every marketing decision, every staffing decision, every policy decision, should be considered in the light of that decision's detriment or complement to the quality of life within the practice. Size or Quality? You can have both!

Accepting Assignment of Insurance Benefits

  We have always recommended that our clients accept assignment of insurance benefits. It requires some extra work, of course, but the payoff is far better case acceptance.
  However, the fact that the practice policy may be to accept assignment does not mean that you will accept assignment in all cases. Is it reasonable, for instance, to accept assignment on a "C" patient with four months on the job? Should you accept assignment when you have no information, and cannot obtain information, regarding the specific amount of coverage and/or when payment will be made?
  We continue to see case after case where an account is seriously delinquent simply because the practice blindly accepted assignment of insurance benefits when there was no evidence at all that the insurance would actually cover the amount estimated.
  Dental and orthodontic insurance is a wonderful benefit to patients and an asset to doctors. Having said that, it is not appropriate to accept assignment of insurance benefits without solid and specific knowledge regarding the amount of coverage, that the benefit will be paid directly to the practice, specifically when benefits will be paid, and in orthodontic cases, how the claim should be billed to obtain the optimum benefit. In summary, accept assignment of insurance benefits, but be smart about it!

Delinquent Patients

  One common procedure in many of our new clients' offices is to review the schedule in the morning so the Financial Coordinator can identify patients scheduled for appointments who are past due. The Financial Coordinator then "traps" the patient herself or asks a front desk person to speak to the patient about their delinquency and to collect a payment. They report that this policy works quite well and they are very often able to collect payments in this manner.
  I wonder how many of these patients no-show or cancel their appointments the next time they are delinquent! Instead of simply a financial problem, now you have a clinical problem as well, created only because of your style or method of collection activity.
  If your patients are past due, make quality telephone collection calls to them. If those calls are unproductive, then switch to collection letters. As long as your calls and letters are well written, timely, and as aggressive as the degree of delinquency justifies, you will be more successful in your delinquency control activity and you will avoid the problem with missed appointments, at least the ones related to your collection activity.

Answering Machines

  I am absolutely blown away, flabbergasted, amazed, surprised, etc., when we call a doctor's office and get an answering machine that does not take messages or get a message that says something like "we are too busy to answer your call right now - please call back later". My only thought is that this is a doctor who much more interested in keeping his/her administrative staff happy than in serving the patients that provide the production, income, and profitability of the practice.
  Wake up and smell the roses! If practice growth is one of your goals, you must be available to your patients and your prospective patients! Do not have an answering machine on during working hours! After hours, be certain your answering machine takes messages!

Managed Care

  More and more doctors are making the decision to cancel their participation with Managed Care organizations, virtually always with outstanding results. It is a rare practice that does not have a dramatic increase in net, and a significant improvement in the quality of life, within a very short time after saying "good-bye" to their last managed care plan. Let us show you how!

Purpose of Collection Activity

  Most delinquent accounts are not delinquent because patients are "deadbeats," "credit criminals" or anything of this nature. They are delinquent, but the delinquency is, most often, due to the fact that consistent and credible collection activity has not been done in the past. Sometimes that is due to inadequate staffing, to poor job descriptions, or to proper systems of delinquency control not being in place, but often it is due to a lack of focus on or awareness of the real purpose for collection activity.
  The purpose of collection activity is not to collect payments! The primary purpose of collection activity is to eliminate delinquency and the patient related problems associated with delinquency.
  The first goal in the delinquency control process is to get the delinquent patient back into a quality financial relationship with the practice. If your collection activity does not accomplish this goal, you are going to lose the patient, the dollar value of all the work he might have had done, and the dollar value of all the work that might have been done on the patients he referred to your office.
  Nevertheless, if you cannot accomplish your first goal, the account must be written off the books. If the patient is also causing administrative, clinical, or social problems within the practice, then the patient should be dismissed from the practice. Although bad debt accounts are reported to the credit bureau as a write-off and placed in the patient's credit report, collection agencies, attorneys, small claims court, etc., should not be used!
  If the doctor and the Financial Coordinator understand the true purpose of collection activity, they will understand that when obtaining a quality financial arrangement is not possible, writing off an account balance and dismissing a patient from the practice represents the success, not the failure, of the credit management system.

Credit Report Rules

  All of our clients, and (I hope!) most of those reading this newsletter, obtain credit reports on their patients. Here are some "rules" to follow when doing so.

• Always sign up with the credit bureau directly and obtain your credit reports directly from them. Do not use a credit report service. Such organizations are very expensive.
• Never request joint reports. It is more expensive and does not give you any useful additional information.
• Do not request credit scores (Beacon/Fair Isaaks, etc.). Credit scores are expensive and they provide information that is useless in the dental environment.
• Except in New York and Vermont, permission is not required to obtain credit reports. However, we recommend that your Patient History document notify your patients of your intention to obtain credit reports.
• With only a few exceptions, when requesting reports it is not necessary to enter birth dates, social security numbers, previous addresses, employment information, etc.
• Always use full legal names, including middle initials.
• If a married woman is in the office, always obtain the report on her husband (assuming he is the natural father). I know this seems sexist or inappropriate, but credit reports on men who have been primary wage earners are far more comprehensive than those on women.
• Include a former address when a patient is at their current address less than one year.
• Do not obtain credit reports on step-parents without their specific permission!
• If you get a "No Record" or a credit report that does not seem complete, try DTEC if you use Equifax, or TRCE if you use Trans Union. These features will search the country for a name and address to match a given SS# and will give you the information you need to obtain a comprehensive report on your patient.
• If your computer is Windows capable, call the credit bureau and purchase their Windows software to obtain credit reports. It is faster. Do not use the Internet to obtain credit reports.

Buying A Computer?

  A few days before publishing this newsletter, one of our larger sized practices purchased a new computer system. Normally that is good news, but this doctor replaced a very good, solid, computer system, one that was working very well for him, with one that looks great in a trade show demo, does wonderful digital imaging, treatment card, etc., but does very poorly with patient accounting, the tracking of practice statistics, insurance billing, etc.
  Don't forget what the primary uses of your office computer are. They are patient tracking, financial accounting, insurance billing, and practice statistical tracking. Purchasing an entirely new computer system, simply to get fancy, clinically related features, is not the best move, unless the new system does the numbers part of the practice extremely well. This one does not and in a few months this office will be quite unhappy with their decision. Don't you make the same mistake!