Pound foolish: Cost as a factor in treatment decisions

Responsible consumers understand the importance of cost when making a purchasing decision. Whether a house, a car or even a pair of shoes, cost is usually one of the most important factors that influence the decision to buy. But when it comes to dental care, cost shouldn’t be the determining factor. Unlike housing, transportation or footwear, postponing or forgoing dental treatment can result in irreparable damage. All too often, patients fail to follow treatment recommendations due to expense, putting their oral health at risk. In addition, dentists sometimes make their treatment recommendations based on what a patient’s insurance plan will cover.

The Dentists Insurance Company reports calls to the Risk Management Advice Line from dentists whose patients have refused care based on the cost. While budgetary limitations are certainly a reality of life, dentists are advised to proceed with caution when allowing patients to dictate care. In doing so, they can set themselves up for allegations of supervised neglect.

In one case reported to TDIC, a patient presented for a crown and buildup on a tooth that the dentist had previously treated with a root canal. The patient made a partial payment at the end of his appointment and sent a check for the remainder of his balance a few days later. The check bounced. The office called the patient to advise him of the issue with the bounced check and informed him that the dentist could not deliver his permanent crown until he took care of the outstanding balance.

A few months later, the office received a request for records from another dental office, stating that the patient was being treated for an extraction and an implant for the same tooth. Subsequently, the patient sent an email to the original dentist, demanding that the office pay for the additional treatment. In an effort to compromise with the patient, the dentist offered the patient a refund, which the patient refused. The patient retained an attorney and demanded $10,000. The dentist’s lack of follow up, failure to disclose the risks associated with delaying treatment and decision to withhold care led to the case being settled for $3,500.

“When a patient remains in a temporary crown for an extended period of time, the chances of something adverse happening to that tooth increase,” said TDIC Risk Management analyst Taiba Solaiman. “The dentist could be responsible for replacement of that tooth if treatment was withheld due to an unpaid bill.”

Solaiman warns that withholding treatment due to a patient’s inability or unwillingness to pay may constitute patient abandonment. Even if patients have not fulfilled their financial obligation, dentists should complete the treatment and then pursue the unpaid balance in accordance with office policy.

TDIC reports some cases in which a patient offers to sign a form relieving the dentist of liability based on the patient’s own decision to decline the treatment recommendation. However, no such form exists, and patients cannot sign away their right to receive appropriate treatment or to prohibit themselves from later filing a claim.

Oftentimes, patients use the cost of treatment as a way of delaying necessary care or attempting to negotiate a discounted price for a procedure. TDIC recommends keeping clinical and financial discussions separate and to defer any discussion of payment options to administrative staff. Rather, dentists should focus on clinical treatment needs, including any potential health risks of noncompliance. For patients who delay or refuse treatment based upon financial considerations, the following responses can be helpful:

  • “My treatment recommendations are made regardless of a patient’s payment source or financial status. With respect to the cost of care, I would encourage you to speak with my patient account representative regarding possible payment options.”
  • “I certainly understand that expense is a concern. We have many different financing options. Perhaps we can find something that meets your needs.”
  • “While I can appreciate your financial position, it does not change my diagnosis and treatment recommendation. I would strongly encourage you to do what you can to receive the treatment without delay as our goal is that you maintain optimal dental health.”

Alternatively, dentists can refer patients to a clinic or dental school, where the optimum treatment may be able to be obtained at a lower cost. Provide these referrals in writing and document all conversations in the patient’s chart.

Should a patient become argumentative or attempt to dictate treatment, or if the patient fails to obtain treatment by an established date, TDIC recommends dismissing him or her following a formal dismissal protocol. These conversations should be documented thoroughly.

Dentists are professionally and ethically responsible to present treatment options that are most appropriate for patients’ clinical needs. While cost is certainly a factor in any decision, it should not be the only factor, and dentists should educate patients on the risks associated with failing to complete recommended treatment. When all else fails, it is appropriate to dismiss noncompliant patients from care in order to protect yourself and your practice from risk.

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can answer treatment decisions and other questions related to a dental practice.

Reprinted from the CDA Journal.

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