When it comes to treating special needs patients, dentists not only embrace the opportunity to provide quality care but also recognize the importance of understanding the liability implications. It's a topic that demands attention as dentists navigate the fine lines between providing comprehensive treatment, patient safety and avoiding potential risks.
The Dentist Insurance Company provides a no-cost Risk Management Advice Line to help CDA members and TDIC policyholders navigate challenging situations, like working with special needs patients and their caregivers. As one call to the Advice Line illustrates, dentists need more than compassion in these situations. Effective communication and a basic understanding of the Americans with Disabilities Act are important tools to reduce risk and improve care for this patient populations.
A case study on AwDA violations
One dentist received a new patient appointment request online from a woman who was the caregiver of a daughter with special needs. The mother was seeking an appointment for her daughter, who appeared to have an infected tooth. In her request, the mother explained that her daughter had anxiety and high-functioning autism.
After reviewing the appointment request, the dentist authorized his staff to respond with the following email:
You must contact your insurance to be referred to a facility offering the dental services that your daughter needs. The services that you are requesting are not offered or provided to any patient coming to this office. We do not have sedation services, general anesthesia services and we are not trained to treat patients with "anxiety disorders and high-functioning autism,” as you mentioned your daughter has. We perform dental treatments for patients with disabilities when they can cooperate 100 % to the treatment with the use of regular local anesthesia, under the same conditions as any other patient without disabilities. The fact that we treat patients from Medi-Cal does not mean that we are able to treat all patients, nor are we obligated to accept all cases. Please contact your insurance [plan] and get solutions from them.
It is understandable that this email was not well-received by the patient’s parent, who responded with justified concerns that the dentist refused to make an appointment without offering an initial consultation or even asking questions about the patient’s potential tolerance of treatment or dental history. The parent pointed out that their response to her was in violation of the Americans with Disabilities Act (AwDA), and she would be filing complaints with the Civil Rights Division of the Department of Justice, the California Department of Consumer Affairs and the American Dental Association, as well as considering a civil suit for damages.
What went wrong
While at first glance it may seem that this situation escalated quickly, the patient’s caregiver was not mistaken: the dentist’s response was a clear violation of AwDA. Let’s look at how the response violated AwDA and how the situation could have been better handled.
Violation: “The services that you are requesting are not offered or provided to any patient coming to this office.”
It’s important to point out that the only service that had been requested by the parent on behalf of her special needs daughter was a consultation for a suspected infected tooth. The parent had not asked for sedation services or anesthesia. Instead, the dentist assumed that since the patient had an anxiety disorder and autism that those would be required.
In certain cases, dentists may determine that they are unable to provide treatment without violating AwDA guidelines. This can occur when a patient's medical condition poses a significant risk to their health, or when the necessary accommodation cannot be reasonably made within the dental practice. The dentist in this situation jumped to conclusions about the patient’s mental and emotional state and failed to assess and determine whether his office could safely make accommodations based on the patient’s actual needs and health history.
Violation: “You must contact your insurance [plan] to be referred to a facility offering the dental services that your daughter needs.”
The dentist suggested – more than once– that the patient’s insurance plan would be able to direct them to a provider. Compliance with AwDA necessitates that when appropriate treatment requires accommodations that cannot be safely offered by the practice, such as general anesthesia, the dentist should provide a referral to another provider that can provide treatment.
In such instances, it is appropriate to refer the patient to a specialist or alternative healthcare provider who can better accommodate their needs. It is essential to communicate the referral process clearly to caregivers, providing them with information on specialized providers who can address their loved one's unique requirements. Simply directing them to get names from their insurer is not considered an appropriate referral and could potentially put a patient at risk by prolonging discomfort and postponing necessary treatment.
Violation: “We are not trained to treat patients with "anxiety disorders and high-functioning autism.”
Basing the denial of treatment on the dentists’ lack of training for treating patients with special needs was factually incorrect. The dentist and his staff had adequate training to be able to assess and diagnose the patient’s tooth pain, so long as an extraordinary accommodation was not required to do so. Without adequately assessing the patient’s needs through either additional communication with her caregiver or an in-person consultation, the dentist had no basis for stating his office wasn’t equipped to treat the patient.
The American Dental Association revised their Principles of Ethics and Code of Professional Conduct to better reflect the rights of patients with disabilities in providers' patient selection. This revision prohibits dental professionals from denying care to patients with physical, developmental, and mental impairments. A lack of confidence in treating patients with special needs should not be equated with a lack of training. To practice ethically and within AwDA compliance, ensure that as a minimum, you can offer basic treatment to patients with special needs.
In this particular situation, the Risk Management Advice Line analyst who spoke with the dentist reminded him that many patients with physical or developmental special needs can be treated within the practice with reasonable accommodations. The analyst discussed the importance of establishing protocols to provide patients an opportunity for an in-person assessment to determine whether the patient's needs can be met and accommodated by the practice, thus preventing future problems. The dentist was referred by the analyst to an attorney for additional guidance.
Protocols that effectively prevent violations
It is critical for dentists to be able to assess and evaluate whether they will be well-equipped to provide comprehensive care to patients with special needs. Establish open lines of communication with both caregivers and special needs patients, as caregivers possess valuable information about the patient's medical history, communication preferences and specific needs. By actively listening to caregivers and addressing their concerns, dentists can develop trust and ensure that treatment plans are tailored to the patient. Additionally, awareness of the Americans with Disabilities Act (AwDA) guidelines helps dentists determine when referral to a specialist is necessary to provide appropriate care. By embracing these practices, dental professionals can uphold the principles of inclusivity and high-quality care that patients with special needs deserve.
TDIC’s Risk Management Advice Line is a benefit of CDA membership. Schedule a consultation with an experienced risk management analyst or call1.877.269.8844. Reprinted with permission from the California Dental Association, copyright September 2023.