Risk Management analysts share top three concerns

Practice owners who have questions about dismissing a patient, giving a refund or terminating an employee are not alone. The Dentists Insurance Company reports these are the top three risk management issues facing dentists today.

In fact, these issues make up the majority of calls received through the Risk Management Advice Line, TDIC Risk Management analysts say. While no two cases are exactly the same, they often follow similar patterns. Following are real-life calls and recommendations offered by TDIC RM analysts.

Patient dismissals

In one case reported to the Risk Management Advice Line, a patient refused to have her permanent crown seated. The patient had been wearing a temporary crown for more than two months. She came in for the final cementation, but she was not happy about the shade. The dentist sent it back to the lab to have it redone. The office called the patient several times, but she would not return to have the crown seated.

The dentist had already redone several restorations in the past, because the patient was very selective. The patient said she was disappointed that the crown was the wrong color and she was tired of the dentist always making mistakes, so she decided to have a new dentist make her final crown. The dentist was frustrated because he spent a significant amount of his chairside time in addition to money for the lab fees, only to have her not follow through with treatment. The dentist wanted to know whether he could charge the patient for the lab fees he had paid to date. He also wanted to know whether he was required to provide 30 days of emergency care.

RM analysts advised the dentist to follow up with a patient termination letter that indicates the patient ended the relationship. The letter should outline the risks associated with wearing a temporary crown. Because the patient terminated the relationship, the dentist is not required to provide 30 days of emergency care.

Some insurance companies do not allow dentists to charge separately for lab fees. If there was no insurance and the patient paid cash, the dentist has the right to charge for services provided if these fees were explained to the patient prior to treatment. However, the dentist was advised that charging these fees could prompt the patient to file a grievance with her insurance company, lodge a complaint with the dental board or post negative reviews on social media. Sometimes, the repercussions can be worse than the loss incurred when waiving a fee.

Patient refunds

TDIC reports a case in which a dentist prepped a tooth for a crown. The dentist had placed several other crowns for this patient, and the procedures always went smoothly. The patient returned several times to the office with postoperative pain. The patient was very concerned that something was wrong and asked the dentist to redo the crown. The dentist believed the patient’s pain was endodontic in origin and suggested a root canal. They went over the charges and the patient begrudgingly paid the additional fee. The root canal was uneventful and the patient’s pain resolved. Later, the patient sent an angry email demanding a refund for the root canal claiming she was not warned before the crown preparation that a root canal could become necessary. The patient threatened to take legal action if she did not receive a full refund.

After the doctor evaluated the chart, he realized that the patient had not signed a consent form, nor did the dentist’s notes reflect a conversation about the risks, benefits and alternatives related to crowns.

The RM analyst confirmed that there was very little documentation indicating that the patient understood the risks and suggested that it might be a good idea to agree to a refund. TDIC recommended having a consent form signed and reviewed for each tooth or appointment. In addition, the analyst advised that continuing the relationship with this patient may be less than ideal because the patient appeared to have lost confidence in his abilities. The analyst suggested that given the patient’s current dissatisfaction, the doctor should consider dismissing the patient from the practice following formal dismissal protocols.

Employee termination

In another call to the RM Advice Line, a dentist reported that a registered dental assistant employed for just under a year showed up late for work, rolled her eyes at other employees and forgot to order supplies. The employee consistently brought her personal issues into the office and was frank and open about her life and activities outside of work. This interaction would often make the doctor and staff feel uncomfortable, and they didn’t really know how to change the topic of conversation. She always apologized afterward, but the inappropriate behavior continued.

Ultimately, the dentist decided that this relationship was no longer working out and the employee was not a good fit for the office. However, neither the dentist nor the office manager had ever officially sat down with the employee to discuss these issues because they assumed she was aware of her behavior and her failure to meet the employment standards expected of her. The dentist and office manager eventually set a date to move forward with termination but failed to follow through due to a busy office schedule. Two weeks later, the employee informed the office manager that she was pregnant and went home sick. The dentist was committed to moving forward with termination due to the ongoing performance issues.

RM analysts acknowledged that terminating an employee is never an easy decision and the situation had taken on another level of complexity given the employee’s notification of her pregnancy. The matter was further complicated by the dentist’s failure to follow through on the earlier decision to terminate the employee as well as his failure to document the employee’s prior performance issues. When dentists are considering terminating an employee, especially an employee in a protected class such as pregnancy status, it is always best to speak to an employment attorney before taking that step. The analyst referred the doctor to an attorney specializing in employment liability for further assistance.

Practice owners face a variety of employee- and patient-related situations that require a unique approach to resolution. But it is possible for dentists to avoid risk by following a few guidelines learned through common scenarios in the dental office.

For individual concerns, contact the TDIC Risk Management Advice Line at 800.733.0633 or visit tdicinsurance.com/advice-line.

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