When it comes to dental care, patient satisfaction is key, However, despite our best intentions, things may not always go as planned. Patient complaints and grievances can sometimes arise, such as for treatment that didn’t meet expectations or disputed billing. Most often, patients’ complaints and grievances stem from a lack of trust in the office and/or doctor.
As an associate dentist, be aware that grievances, audits and dental board complaints can impact your license. Always take an active role in responding to complaints and grievances; a complaint you receive should be treated no differently than that received by the practice owner.
California’s Department of Managed Healthcare and Department of Insurance require dental plans to have quality management, utilization review and anti-fraud systems, including grievance and audit processes, in place to protect patients. The Dental Board of California, as a consumer agency, is also obligated to investigate complaints made to the agency by patients, attorneys for patients, other dentists or employees.
Pro tip:Documentation plays a crucial role in resolving disputes, ensuring transparency and safeguarding your dental license. Clear, organized and accurate documentation, from treatment records to billing statements, can help both patients and dental professionals navigate grievances and audits more effectively. Note: Never backdate chart entries under any circumstances.
Responding to Complaints/Grievances
Responding to a patient’s concerns about their dental treatment is crucial for maintaining trust, regardless of whether it’s an informal complaint or a grievance filed with their dental plan or the dental board.
Take the following recommended steps if a patient files a complaint with your office or a formal grievance:
- Review the complaint or grievance. Carefully read the details to understand the specifics of the patient’s concerns.
- Gather information. Collect all relevant information related to the case, including patient records, treatment notes, billing statements, radiographs/imaging and communication history with the patient.
- Assess the situation. Evaluate the complaint or grievance in the context of the patient’s treatment, your dental practice’s policies and the dental plan processing/payment guidelines.
- The patient may have a false perception based on poor communication from the dental plan, the office staff or friends and family. Try to determine why the patient feels this way.
- Communicate. When necessary and appropriate, reach out to the patient to acknowledge their complaint or grievance. This can be done by phone or a written response. Express empathy and willingness to resolve the issue. Collect any additional details from the patient to help you understand their issues.
- Investigate. Conduct a thorough investigation, which may involve speaking with team members involved in the patient’s care and reviewing procedures related to the complaint or grievance.
- Prepare a response. Draft a formal response or narrative addressing the patient’s concerns. Be clear, concise and informative, include findings from the investigation and outline steps taken to address the complaint or grievance. The response should be clinical in nature and based on facts, not assumptions or judgements.
- Submit documentation. For grievances, send your response and any supporting documentation to the entity that forwarded the grievance (dental plan or dental board). Make sure the response complies with the entity’s requirements for handling grievances.
- Follow-up. After submitting the response to the entity, follow up to confirm it is being processed.
- Implement necessary changes. If your grievance investigation reveals systemic issues, consider making changes to practice protocols, staff training or communication processes to prevent similar issues in the future.
- Document the process. Keep detailed records of all communication, including the complaint or grievance, the response and any actions taken, for future reference and compliance purposes.
- Review and reflect. After the complaint or grievance is resolved, review the case internally to identify lessons learned and improve overall patient care and service.
Audits
When a dental office is audited by a dental plan, the billing dentist or practice owner is most accountable. However, associate dentists still play an integral part in the audit process.
Consider the following if you or the practice that employs you is audited by a dental plan:
- Stay calm and professional. Maintain a composed demeanor. An audit can be stressful, but professionalism is crucial.
- Understand the audit process. Each plan may have a slightly different process, so check the provider manual, provider website or contact the plan directly for details of their procedures.
- Identify the documentation requested by the plan:
- Patient records: Collect all relevant patient files, including treatment notes, consent forms and imaging. Important note: The dental plan requesting the audit is entitled to review only the portion of the patient’s chart that correlates with the time frame the patient was enrolled with that dental plan.
- Billing records: Include all claims submitted, including codes used and payment received.
- Review your documentation. Conduct an audit of your records to ensure everything is complete and accurate. Look for any discrepancies or areas that may raise questions.
- Consult with team. The entire dental team can be involved in the process. Ensure everyone understands their role and can provide information if needed.
- Communicate with the auditor. Designate a point person (often the office manager) to communicate with the auditor. This helps maintain clarity and organization.
- Seek professional advice. Consider consulting with an attorney or compliance expert who specializes in dental audits to guide you through the process. CDA’s expert analysts are very knowledgeable in the audit process.
- Respond promptly. If the auditor requests additional information, respond quickly and provide the necessary documentation to avoid delays.
- Document everything. Keep detailed records of all communications, submissions, and any findings from the audit. This documentation can be useful in case of disputes.
- Review audit findings. Once the audit is complete, carefully review the findings. Address promptly any discrepancies or areas of concern. The office will have the opportunity to appeal any audit findings by providing additional documentation and/or narrative evidence.
- Implement changes. An audit will often reveal areas for improvement. Be prepared to implement changes in the practice to enhance compliance and reduce the risk of future audits. After the audit, review the findings with the dental team to reinforce best practices in documentation, billing, and compliance.
- Follow-up: Ensure any action items resulting from the audit (e.g., returning funds or appealing a decision) are completed in a timely manner.
See additional information related to audits, complaints and dental board or dental plan grievances: