1 Managing for Dental Program SuccessNCCHCA Primary Care Conference Sharon Nicholson Harrell, DDS, MPH, FAGD

2 Fun Facts about Winston-Salem

3 Did you know ? Winston-Salem ranks in the top five cities in North Carolina based on population. Where does it rank? What famous company that is known to satisfy many a “sweet tooth” and is famous for its “hot and now” was invented in Winston-Salem? What is the name of the city that was originally formed by the Germans as a Moravian settlement and can still be visited today?

4 About Safety Net SolutionsSafety Net Solutions (SNS) is a program of the DentaQuest Institute (DQI). DQI is part of the DentaQuest Enterprise whose mission is to improve the oral health of all. DQI is an improvement organization focused on creating an effective and efficient oral health care delivery system. SNS provides practice management technical assistance consulting to safety net dental programs helping them achieve their goals in areas such as increased access, strengthened financial viability, and improved quality outcomes.

5 43 states + District of Columbia; Close to 500 programsAll states other than left to right, Nevada, Utah, Wyoming, Nebraska, Arkansas, Alabama, and West Virginia

6 Sharon Harrell, DDS, MPH, FAGD, FICDExpert Advisor, Safety Net Solutions Currently Dental Director, FirstHealth Dental Care - almost 20 years Dental Director, Cumberland County Health Department Staff Dentist, York Health Corporation Federally Qualified Comm Health Center Adjunct Associate Professor, UNC- School of Dentistry, Departments of Dental Ecology & Operative Dentistry B.A. Chemistry ‘83, DDS ‘87, MPH ‘90, University of North Carolina at Chapel Hill Advanced General Dentistry Residency Program, University of Maryland Dental School Distinguished Service Award, University of North Carolina Dental Alumni Association, April 2015 Fellowship in AGD, Pierre Fauchard, International College Before we dive into the weeds and utilization of interactive tools we really need to take a look at the total picture and be able to understand “What Success Should Look Like” in a health center dental program. A key word or principle to guide us in our definition of “Success” is Balance. There actually are a lot of moving parts to know and understand in putting together a successful strategy or plan to build an effective and efficient dental program and when you understand them and own them it is actually not rocket science to plan it and execute it. Our problem has always been the fact that no one teaches us how to understand the pieces and put them together in a continuous, coordinated, comprehensive way and then to evaluate if anyone learned anything and is going to use anything they learned. Going forward all of us involved in these webinars and group trainings from SNS at DentaQuest, NNOHA, HRSA and NACHC intend to close that gap in training and create a training curriculum and methodology that gives everyone responsible for health center dental programs the training and tools needed to be successful. So, in order to define what success will look like for your program, we need to take a step back and understand what the moving parts are in dental so that you can determine what type of balance you need to create between them. One of the first things we need to realize is that Margin helps drive Mission. So, what is Margin and what makes up Mission in dental ?

7 The Fundamental TruthsYou can’t run a dental department like a medical department (no matter how hard you try!) But you CAN run a dental department like a dental department And you CAN create a dental department that is results-driven and financially sustainable

8 Keys to Dental Program SuccessThe first key to dental program success is realizing that dental is different from medical!!!! The business model and the models of care for dental and medical are different How so?

9 Medical Dental 80% of clinic volume 80% of visits similar 80% of visits = shorter (15) 80% of billing similar 80% of visits diagnostic 100% of governance is designed around medical EMR silo Familiar with medical model Confident leadership 80 % of care in FQHCs is in primary care and 20 % of care happens in dental. There is a huge difference in not only volume but also in capacity. Dental capacity is 1/5th of medical . We need to acknowledge that capacity deficit and then prioritize what patients we prioritize to treat . The worst thing we can do is try to fit all those PC patients into dental appointments. That leads to episodic, fragmented care which is the WORST type of quality we can offer. One of the first things to realize is that your dental clinic does not have the capacity to treat all of your HC patients. Thus it is necessary to determine who we treat and why. This is the concept of justification. The Justification concept is very important to know and use . It helps us defend and describe our decisions. 80 % of medical appointments are very similar. The Doc listens to the CC, takes vitals and examines the PT. , makes a DX and prescribes a treatment or refers the Pt. 80% of dental appointments are varied: One filling, maybe two fillings or three fillings. Each filling can be simple, compound or complex. Materials are different. Anesthesia is different. Then there are extractions also with variety, root canals etc. Even the preventive visits vary. 80% of medical visits are minutes. 80 % of dental visits average 40 minutes. The billing for 80% of medical visits is similar/ dental billing is extremely varied 80 % of medical visits are diagnostic while 80% of dental visits end in some type of hands on and time sensitive treatment. 100% of RVUs for medical visits are similar while 80% of RVUs in dental visits are varied due to the complexity and time of the procedure. 100% of FQHC governance is designed around medical while very little governance is designed around dental. Governance is most often retro fit to dental. EMRs and EDRs were designed independently and do not interface or talk in most cases creating siloed Health Information! We are familiar with the medical model because we have been doing it longer and it represents 80% of our business and care. Thus we are confident and comfortable with the medical model but we are unfamiliar and awkward with the dental model . We try to use the medical model in dental and when it fails the alternative is to step away and avoid it very often leading dental by avoidance unless something urgent occurs. 20% of clinic volume 80% of visits varied 80% of visits = longer (45) 80% of billing varied 80% of visits treatment 0% of governance is designed around dental EDR silo Not familiar with dental model Less confidence 9

10 How Medical and Dental DifferThe procedure-oriented and time sensitive nature of dental must be considered when developing both clinic revenue goals and financial parameters Over capacity can occur when we do not take these differences into consideration

11 Common Trap in Dental: Over CapacityOnly 20% of the clinical volume of Medical = 1/5 of the capacity of Medical In Dental, we are limited by our structure # Operatories # Dentists, #Dental Assistants # Dental Hygienists, # Staff (front desk; billing) Quality Care mandates that we work within our Capacity When we understand and define Capacity we then create our access goals Structure + Process= Outcomes in dental Our structure determines our capacity not our hearts We cannot be everything to every patient We only have 20% of the capacity of Medicine We need to decide WHO gets the care Equitable, quality care mandates that we work within our capacity When we understand and define capacity we then create our business plan Dental Care should be : Safe; Equitable; Efficient; Effective; Timely and Patient Centered.

12 Factors Impacting CapacityOur patient population (affects length of appt) Serve primarily adults, children or a mix? Provider skill levels (affects patient flow) Students/externs Recent graduates Advanced dentists Staffing Model General Dentists, RDHs, Pediatric Dentists, etc. Mark can elaborate.

13 Signs of Over or Under CapacityToo Many Patients (Over Capacity): Overwhelming demand and trying to take care of too many patients Patients are unable to return for care in a timely fashion to complete their treatment Too Few Patients (Under Capacity) Lack of demand and trouble filling the schedule Patients could be unhappy with the care Competition in the area Not enough patients to draw from (lack of needs assessment prior to opening)

14 Too many new patients can lead to over capacityNew patients are the lifeblood of any practice The number of new patients should equal the number of patients you completed treatment on Number of new patients is measured by the number of comprehensive oral evals (D0150) Need to determine the number of new patients the practice can manage

15 Common Barriers to SuccessOver Capacity is a leading barrier to success No-Shows and Last Minute Cancellations leading to high broken appointment rate (sometimes due to over capacity) Lack of Scheduling that maximizes productivity and financial viability Dentist Issues (unmotivated, inexperienced, lack of accountability)

16 Common Barriers to SuccessStaffing Issues (insufficient number of dental assistants, inexperienced front desk) Lack of Documentation of eligibility for insurance Inability to collect co-payments from patients with insurance or payment from self-pay patients Billing (Denied Claims, missed deadline to resubmit) Collections issues (high A/R)

17 Common Barriers to SuccessNo nominal fee for patients at or below 100% of federal poverty level Outdated sliding fee scale/ Standard fee not at % of usual and customary (UCR)—carries risk that standard fee is below reimbursement amount from insurance Unfavorable payer mix Inability to generate practice performance data

18 Let’s hear from you!! WHAT ARE YOUR BARRIERS TO SUCCESS?

19 Self-Assessment of your Dental ProgramUse the Self-Assessment Questionnaire designed by Safety Net Solutions to help your dental program identify barriers to success Seven of the most common barriers to success will be covered Rate the following barriers to success as follows from 1 to 4 by a show of hands: 1 No difficulty with this issue 2 Minor difficulty with this issue 3 Moderate difficulty with this issue 4 Major difficulty with this issue

20 Self-Assessment of your Dental Program1. Managing no-show patients effectively 1 No difficulty with this issue 2 Minor difficulty with this issue 3 Moderate difficulty with this issue 4 Major difficulty with this issue Scheduling to maximize productivity and financial viability

21 Self-Assessment of your Dental ProgramBilling (denied claims, missed deadline to re-submit) 1 No difficulty with this issue 2 Minor difficulty with this issue 3 Moderate difficulty with this issue 4 Major difficulty with this issue 4. Documentation of Eligibility

22 Self-Assessment of your Dental Program5. Collecting co-payments from patients with insurance/self-pay patients 1 No difficulty with this issue 2 Minor difficulty with this issue 3 Moderate difficulty with this issue 4 Major difficulty with this issue 6. Setting appropriate fee schedule for the practice

23 Self-Assessment of your Dental ProgramDeveloping appropriate financial and productivity goals 1 No difficulty with this issue 2 Minor difficulty with this issue 3 Moderate difficulty with this issue 4 Major difficulty with this issue

24 You’ve identified the Barriers to SuccessNow, let’s learn about the solutions!!!

25 Managing No Shows—Benchmark is 15%Create a strong no-show policy and enforce it! Educate patients about the policy and why it is necessary (can put someone else in the appointment slot/ helps us stay afloat so we can continue to provide dental services) Ask patients to read and sign the No-Show policy and put it in the hard copy chart or scan it into the electronic chart /ask if they have questions

26 Managing No Shows—Benchmark is 15%Enforce it consistently—everyone, from the front desk to clinical staff to CEO to the board members needs to be on the same page—no exceptions! By doing this, you begin to hold your patients accountable--with time and consistency, you will establish a core of prompt, reliable patients who appreciate the value of dental appointments and will abide by your practice’s policies

27 Managing No Shows—Benchmark is 15%Some sample policies: If patient misses twice in a 6 month period/12 month period, they will not be scheduled for future appointment for a year except for emergencies/ they are welcome to call in the morning to see if any cancellations Track no-shows to monitor success because not tracking = not knowing Formula for broken appointment rate is: # of broken appointments/# of appointments made = # of broken appointments + # of visits: If 10 pts broke and 40 came, the formula is 10/10+40= 10/50= 20% broken appointment rate

28 Managing No Shows—Benchmark is 15%Strategically manage no-shows by scheduling appointments no farther than days out because patients tend to break appointments if scheduled too far out Safety Net Solutions does not recommend double booking due to the chaos that occurs when everyone shows, but consider double “judicious double booking” for patients who cannot be confirmed/times when broken appointments tend to occur such as Friday afternoons, for example

29 Managing No Shows—Benchmark is 15%Make reminder calls 48 hours in advance and consider removing (or double-booking) appointments for patients who don’t have a working phone / Consider s and texts. One approach: When forced to leave a voic message while confirming appointments, require the patient to call back no later than the day before scheduled appointment to confirm If patients do not respond/confirm, their appointment will be removed from the schedule (or double-booked)

30 Scheduling Solutions Create a formal scheduling policy. For example, do not schedule children under age 4 for operative appointments in the afternoon Create cheat sheets for appointment lengths and procedures so Front Desk staff will know how to schedule appointments appropriately, i.e. root canal treatment is 80 minutes and recall appointment is 40 minutes

31 Scheduling Solutions Make only one appointment at a time unless it is a multi-visit appointment like dentures Do not schedule more than 2 family members at a time unless they have a proven track record of showing up Determine where emergency slots will be placed and the number of emergency slots that can be accommodated per day.

32 Billing Issues Denied ClaimsThe best way to avoid denied claims is to submit correctly the first time; know which procedures are covered and be aware of the frequency with which procedures will be covered. For example, under North Carolina Medicaid, premolar sealants are no longer covered Denied claims to NC Medicaid can be submitted for up to 18 months after the claim was denied.

33 Billing Issues Denied ClaimsProcedures that were not billed to NC Medicaid can be billed for up to one year from the date of service Designate someone to “spot check” to make sure that treatment rendered per the clinical note was charged out and charged out correctly, i.e was the periapical x-ray with the limited charged out or was the filling actually 2 surfaces rather than 1 surface?

34 Documentation of EligibilityOops!!!! Patient not eligible Determine insurance eligibility BEFORE the patient arrives for the appointment Checking eligibility before the appointment is confirmed allows the office to contact the ineligible patient so they can troubleshoot with the insurance carrier

35 Documentation of EligibilityPatient Eligibility: The practice has 3 options for non-emergent patients who show up and the office is unable to verify private insurance or Medicaid/Health Choice eligibility: 1. Provide services anyway (understanding the risk that these services may go unreimbursed) 2. Provide the minimum necessary services and postpone the remainder until coverage can be confirmed. 3. Offer the patient the option to be either rescheduled for a time when eligibility can be verified, or pay out of pocket for the visit.

36 Documentation of EligibilityPatient Eligibility: If the patient decides to pay out of pocket, let the patient know you will file their insurance and if the visit is covered, the office will reimburse the patient the out of pocket fee Do not tell the patient you will file and reimburse if you do not have the staff to follow-through to make sure this happens.

37 I didn’t bring any money today! Collecting Payment from PatientsExperience shows that if money is not collected at the time of the visit, it will not be collected The best practice is for payment to be collected BEFORE patient goes back into the clinical area. If there is a chance that the fee will be higher than what patient paid, inform them that they can pay the projected fee before going back, and can pay the extra when they check out. Occasionally, a patient may be due a refund when they check out Never ask the patient “Would you like to pay today?” Inform the patient that “Your fee today is $50. Would you like to pay by cash or credit card?”

38 Collecting Payment Just like with a patient whose eligibility for insurance cannot be determined, the practice has 3 options for non-emergent self-pay patients who show up without money to pay for services or patients with insurance who do not bring their co-pay: 1. Provide services anyway (understanding the risk that these services may go unreimbursed) 2. Provide the minimum necessary services and postpone the remainder until patient can pay 3. Offer the patient the option to be rescheduled for a time when he or she has the money to pay

39 Collecting Payment Typical reasons why dental programs leave money on the table: Provide services that are not covered by third-party payers Provide services to patients who say they have insurance (but don’t) Failure to hold patients accountable for paying their share of charges at the time of the visit

40 Setting an appropriate fee scheduleDetermine whether your standard fee is at 70 – 80% of the usual and customary (UCR) in your area (SNS can assist with determining this amount) The standard fee schedule determines the sliding fee scale If your standard fee is not at 70-80% of the usual and customary in your area, then your sliding fee scale amounts will be less than they should be

41 Setting an appropriate fee scheduleWhile it is prudent to set fees that patients can pay, it is also prudent to assess those fees every year or two as costs to operate the practice increase Be sure to set a nominal fee for uninsured patients at or below 100% of the federal poverty level. These per visit fees usually range from $30 - $50, but can be as low as $10 per visit

42 Setting an appropriate fee scheduleAlways submit your standard fee to Medicaid, Health Choice, and commercial insurance companies, not what they will reimburse you for. Why? Because their reimbursements may increase, but they will only pay you what you submit If you submit a standard fee lower than what the insurance company reimburses , then you are leaving money on the table For example, if Medicaid pays $100 for a procedure, and your standard fee is $98, then Medicaid will only pay $98

43 Setting Productivity/Department GoalsIs the Finance Department able to provide Dental Director with a monthly budget report individualized for dental? This monthly report will show the budgeted and actual production, revenue, and expenses as well as the net income and is the map by which the dental practice’s success is evaluated Key Statistics needed include: Number of visits, # of Procedures by ADA (American Dental Association) codes, # of unduplicated patients, # of new patients, broken appointment rate, payer mix, collection rate, and aging report past 90 days

44 Productivity Benchmarksencounters/year/FTE hygienist encounters/year/FTE dentist 1 patients/50 min. 9 patients/day/hygienist 1.7 patients/hour or 13.6 patients/day/dentist Benchmarks are for comparison only and are not precisely relative to each program. They demonstrate a national average with which to compare ourselves but can vary markedly based upon variables within our programs. When we create protocols of care it is important to consider the community standard of care; what patients expect and or what most other practices actually provide. The Standard of Care is considered what most providers provide in a similar circumstance.

45 2015 UDS National Data AveragesWhat is Everybody Else Doing? 2015 UDS National Data Averages Previous slide had range of 2,500 – 3,200 visits/FTE Dentist However, UDS National Data Averages come in at 2,623 visits/year/FTE Dentist for a panel of 1100 patients Previous slide had range of visits/FTE hygienist However, UDS National Data averages come in 1,240 visits/year/FTE Dental Hygienist r What is Everybody Else Doing? UDS 2015 Calculation Notes: Cost/visit = $2,402,511,871 / 13,157,202 total visits = $182.60/visit 5,192,846 dental patients / 24,295,946 total health center patients = 21.4% Total patients who access services at health center = 30,893,235 patients (not unduplicated) (dental admin allocation) = $807,283,402 / (total admin allocation) = $6,486,655,649 = 12.4% UDS 2014: 2,637 visits/year/FTE DDS 1,237 visits/year/FTE RDH Average cost/visit in dental = $176 2.5 visits/year/unduplicated dental patient Unduplicated dental patients make up 21% of all health center unduplicated patients. Average allocation of health center facility and non-clinical support services to dental = 12.3% Source:

46 Productivity BenchmarksGross charges: $400,000K - $500,000K per full-time dentist per year Gross charges: $150,000- $200,000K per full-time hygienist per year These benchmarks are for comparison only and are not precisely relative to each program; they may vary markedly based on variables and modes of operation in each practice

47 Productivity/Department GoalsDetermining Potential Visit Capacity Potential capacity is based on number of FTE providers, hours of operation and standard productivity benchmarks Benchmarks are different for dentists vs. hygienists 1.7 pts/hour dentist vs 1.2 pts/hr hygienist Potential visit capacity is impacted by factors affecting provider productivity

48 Determining Potential Visit Capacity (Dentists)# of FTE Providers X 1.7 Visits/FTE/Clinical Hour X # of Clinical Hours Potential Visit Capacity Mon. 1 1.7 8 13.6 Tues. 10 17 Wed. 2 3.4 27 Thurs. 3 5.1 40 Friday 4

49 Productivity/Department GoalsExpense/Visit vs. Revenue/Visit Determine the cost per visit (total expenses ÷ visits) Determine the revenue per visit (total net revenue ÷ visits) If revenue/visit is higher than expense/visit, pat yourself on the back and keep up the good work If you’re like the majority of community health dental programs, expense/visit is higher than revenue/visit The difference is what the dental practice needs to make up in each visit to reach sustainability

50 Summary Success looks different for each dental practice based on the community standard of care Key data and benchmarks are needed to determine what success looks like in the individual practice Use the full Self-Assessment Questionnaire to identify barriers to success and utilize the follow-up presentation and the Safety Net Solutions resources to troubleshoot!

51 Follow-up to this Presentation:September 26 – 28, 2017 North Carolina Public Health Association Meeting in Asheville, North Carolina December 1-2, 2017 North Carolina Primary Care Association Meeting in Winston-Salem, North Carolina

52 SNS Technical Assistance ResourcesBest Practice Manual Payer Mix Projection Tool Sample Clinical Protocols Dental Program Performance Tracking Tool Sample Dental Job Descriptions Productivity Benchmark Guide Sample Broken Appointment Policies Sample Scheduling Policy Scripting for CHC Dental Staff Sample Emergency Policy Profit & Loss Budget Variance Tool Sample Quality Assurance Policy Financial and Productivity Goals Tool And much, much more! This is a short list of the many resources we have created over the past ten years working with our partners on redesigns and start up plans.

53 How to Access the DentaQuest Online CenterGo to Click on Learn, then Online Learning Center and then Resource Library Click on the NCCHCA folder Download the presentation, resources and handouts

54 SNS Online Practice Management SeriesGo to Click on Learn, then Online Courseware, then Safety Net Dental Practice Management Series Modules 1 – 7: Developing Billing Excellence Fee Schedules, Sliding Fee Scales, & Management of the Self-Pay Patient Safety Net Dental Program Finance and Productivity: Your Mission and Your Margins Front Desk Customer Service The Front Desk: Creating Your Dream Team Managing Chaos in the Dental Program Scheduling by Design WILL NEED TO REGISTER AS A MEMBER FREE CEUs Available! Need to register as a member

55 Questions/Discussion

56 Partnering to Strengthen and Preserve the Oral Health Safety NetTHANK YOU!!!!! Partnering to Strengthen and Preserve the Oral Health Safety Net 2400 Computer Drive, Westborough, MA Tel: Fax: