fundamentals - d4 practice solutions
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Fundamentalsof Running an Effective FQHC Dental Program
Dori BinghamProgram Manager/Senior AnalystD4 Practice Solutions
Dori Bingham
Program Manager/Senior Analyst
D4 Practice Solutions
Cell: (508) 776-1826
www.d4practicesolutions.com
Part I: Defining Success
• Benchmarks• Goals• Data
FQHC Benchmarks
1,300-1,600 encounters/year/FTE hygienist
2,500-3,200encounters/year/FTE dentist
1.7 patients/houror 14 patients per day for dentists
8-10 patientsper day for hygienists
2,700 encountersper year with 1,100 patient base
Gross Charges =
>$500K-$600K per dentist per year
FQHC Benchmarks
$209 average cost per encounter (UDS 2018)
230 work days/year (or 1600 work hours/year after
holidays and vacations)
330 = 15%Allocation Average
1.5 Assistants/dentist (1 DA per chair is ideal)
2 Chairs/dentist (3:1 is ideal)
2.5 ADA coded services/treatment visit
2 ADA coded servicesas the diagnostic part of a recall or comprehensive visit (exam, FMX)
3 Slide Categories101-199% FPG
FQHC Benchmarks
$30-$50Nominal fee
% of total A/R due past 90 days =
< 15%
Full Fee Schedule70-80% of UCR
• 28.3 million unduplicated FQHC patients84% accessed medical services (23.8 million patients)
22.6% accessed dental services (6.4 million patients)
• 2,630 visits/year/FTE Dentist• 1,151 visits/year/FTE Dental Hygienist• 2.6 visits/year per unduplicated dental patient• Average cost/visit in dental = $209 per visit• Sealant metric average = 52.8%
2018 FQHC UDS National Averages
My Top 10 Priorities for Success• Define Program Goals
• Track Performance
• Define Program Capacity
• Minimize Chaos/Unpredictability
• Maximize Productivity
• Maximize Access
• Maximize Revenue
• Commit to Continuous Quality Improvement
• Develop Accountability
• Maximize Communication
Setting Goals• Access
• Productivity
• Revenue
• Outcomes
Access = Capacity• Finite
• Resource-Based
• Differs from Medical
• Step 1: Determine Potential Capacity
• Step 2: Manage to That Capacity
Structure = Capacity• Operatories• Hours• Staff• Benchmarks
Determine Potential Daily Visit Capacity, Example for Dentists
# of
Dentists
x Benchmark x # of
Chairside
Hours
Potential Visit
Capacity
Mon. 1 1.7 8 14
Tues. 2 1.7 15 26
Wed. 4 1* 30 30
Thurs. 4 1.7 30 51
Fri. 2 1* 15 15
Total 98 136
Weekly potential capacity = 136 (162 with more assistants)Annual potential capacity = 136 x 46 = 6,256 visits (7,452)
*Only one assistant per dentist
Dentist Benchmark
• Could range from 1 visit per hour to 2 or more
• Dentist variables (experience, specialty)
• Support variables (number and type of DAs per dentist)
• Number of operatories
• General dentist with two operatories and two conventional assistants = 1.7 visits/hour
Determine Potential Daily Visit Capacity, Example for Hygienists
# of
Providers
x
Benchmark
x # of
Chairside
Hours
Potential Visit
Capacity
Mon. 2 1.2 15 18
Tues. 2 1.2 15 18
Wed. 2 1.2 15 18
Thurs. 2 1.2 15 18
Fri. 1 1.2 7.5 9
Total 67.5 81
Weekly potential capacity = 81Annual potential capacity = 81 x 46 = 3,726
Hygienist Benchmark
• Could range from 1 visit per hour to 2 or more
• Hygienist variables (experience, assisted vs. non-assisted, dentist to hygienist ratio, age of patients)
Capacity Determines Visit Goals• Weekly = 136 dentist + 81 hygienist = 217 visits
• 217 visits/week x 46 weeks = 9,982 annual visits
THIS is what we shoot for, not more and not less
Number of Unduplicated Patients
• Our STRUCTURE gives us 9,982 annual visits
• 9,982 annual visits ÷ 2.6 visits/patient (2018 UDS) = 3,839 unduplicated patients
THIS is what we shoot for, not more and not less
Number of New Patients
• Depends on new vs. established practice
• Balance of new vs. existing patients is critical
Tracking completed treatments tells us how many new patients we can bring in
Completed Treatments• Phase I
• Designate code (eg, TxCOMP)
• Utilize consistently
• Track
• Every TxCOMP = new patient
• Goal is <12 months from exam to Phase I completion
• Nice quality outcome measure!
Productivity
• More than just the number of visits
• What happens in the visit!
• Who it happens to (who is the patient, what are their needs and what is the payer source for the visit?)
• Number and types of procedures
• Goal = 2.5 ADA coded services per visit
Scope of Service BenchmarksService Type Procedure Codes % of Total
Diagnostic D0100-D0999 (excluding D0140) 30-40%
Preventive D1000-D1999 25-35%
Restorative D2000-D2999 18-25%
Endodontics D3000-D3999 1-2%
Periodontics D4000-D4999 2-5%
Removable Prostho D5000-D5899 1-3%
Fixed Prosthodontics D6200-D6999 <1%
Oral Surgery D7000-D7999 5-10%
Emergency D0140, D9110 2-6%
Revenue: What’s Our Goal?• Break Even
• Operating Surplus
• Operating Loss
• If Loss, How Much?
Operating Costs of DentalDIRECT
• Personnel (salaries, benefits, payroll taxes)
• Dental supplies
• Lab costs
• Occupancy (rent/mortgage, utilities, phone/internet, maintenance)
• Other
INDIRECT
• Administrative Allocation
• Agency/Support Allocations
Setting Revenue Goals, Breakeven• Daily, weekly, monthly, quarterly, annually
• Total costs (direct and indirect) ÷ time
• For example:
Total Annual Cost of Dental Operations
÷ Time = Goal
$1,000,000 230 days $4,348/day
$1,000,000 46 weeks $21,740/week
$1,000,000 12 months $83,334/month
Setting Revenue Goals, Surplus• Determine desired amount of surplus
• Add to total annual cost and divide by time
• For example:
Total Annual Cost of Dental Operations
÷ Time = Goal
$1,000,000 + $100,000
230 days $4,783/day
$1,000,000 + $100,000
46 weeks $23,914/week
$1,000,000 + $100,000
12 months $91,667/month
Outcome Goals• Did We Make Patients
Better?
• Many Measures to Track
• Meaningful, Measurable AND Accurate
• Process vs. Outcome
• Start with one or two
Sample Outcome Goals• HRSA Sealant Measure
• Phase I Treatment Completed
• Reduction in Risk Status
• Preventive Services (eg, Fluoride, SDF)
• National Quality Alliance has others
Part II: Measuring Success
Operating a Dental Practice Without Data is Like Driving a Car Without a Dashboard
Success Metrics• Gross Charges
• Net Revenue
• Expenses
• Number of visits
• Revenue per visit
• Cost per visit
• A/R past 90 days
• # of Unduplicated Patients
• # of New Patients
• # of Procedures
• Scope of Service (types of procedures)
• % of Phase I Treatment Plans Completed
• % of children ages 6-9 at moderate or high risk receiving sealants (UDS)
• Broken Appointment Rate
• Emergency Rate
• Payer/Patient Mix Percentages
Important Reports
• Profit & Loss Statement
• Aging Analysis
• Production Summary Report (procedures)
• Master Provider Schedule
• Utilization/UDS reports
• Practice Analysis
Profit & Loss Statement• By site
• Gross charges, contractual or other adjustments, net patient revenue, grant/other income and total net revenue
• Payer mix?
• Direct and indirect expenses
• Bottom line
Payer Mix• Huge impact on program
success
• Not always contained in P&L
• Tracked for UDS reporting
• Critical information!
Dental Payer Mix
Medicaid Medicaid Managed Care Commercial Self-Pay
Aging Analysis• Money owed to the practice
• Usually broken out by current, then 30, 60, 90, 90+ days
• Big focus: 90 days or beyond
• By payer type
• Sheds light on billing/collections
• 90 days or beyond as % of total A/R (goal <15%)
Production Summary Report• Dental services by ADA code
• Number of times each code was used
• Usually includes total gross charges for each code
• By site
• Total procedures
• Procedures per visit
• Scope of practice
• Outcomes (eg, Phase I treatment completion, sealants)
Master Provider Schedule• Monitor clinical staffing each
day
• Compare potential visit capacity vs. actual visits each day
• Quantify FTEs
• Quantify clinical provider hours each week
• Identify provider gaps
• Identify gaps in support staff
• Evaluate provider performance against goals
Smithfield Clinic Staff Name Staff Type Start AM End PM Lunch Break
Monday Johnson, M Dentist 8 512-1
Murphy, S RDH 10 61-2
Rogers, T DA 8 512-1
Ouelette, J DA 8 512-1
Tuesday Johnson, M Dentist 8 512-1
Sanchez, M Dentist 10 61-2
Murphy, S RDH 10 61-2
Rogers, T DA 8 512-1
Ouelette, J DA 8 512-1
Utilization/UDS Reports/Practice Analysis Reports• Patient Demographics
• Patient Age
• Number of Unduplicated Patients
• Number of New Patients
Evaluating Program Performance• Which reports?
• How often?
• Who will run them?
• How will data be collated?
• How will it be shared?
• How will it be USED?
Dashboards• Simple to Sophisticated
• Excel Spreadsheet to Power BI
• NNOHA has a great dashboard
• Many vendors sell reporting software
• Decide what to use and start tracking!
Still with me???
Part III: Maximizing Success
My Top 10 Priorities for Success• Define Program Goals
• Track Performance
• Define Program Capacity
• Minimize Chaos/Unpredictability
• Maximize Productivity
• Maximize Access
• Maximize Revenue
• Commit to Continuous Quality Improvement
• Develop Accountability
• Maximize Communication
Minimize Chaos and UnpredictabilityTwo Main Culprits: • Broken
Appointments • Emergencies
Why Does This Matter?
• Lost productivity
• Lost revenue
• Wasted chair time
• Diminished access
• Incomplete treatment
• Chaos/unpredictability
• Staff/provider frustration
• Patient frustration
Factors Contributing to Increased BA Rates
• No policy
• Policy weak/not enforced
• Lack of understanding
• Misinterpretation of governance
• No culture of accountability
• Lack of consequences
Broken Appointments Defined
No-Show:A patient is scheduled for an appointment and they do not show up for that appointment.
Late Cancellation:
A patient cancels an appointment less than 24 hours prior to the start of the appointment.
Late Arrival:A patient does not arrive by 10 minutes after the start of their appointment.
Consequences
STRIKE ONE• Reminder and (only) warning
STRIKE TWO• Consequence occurs; requires a proactive
response from patient
STRIKE THREE• Strongest consequence
“Proactive Response” Consequences (2nd Offense)
Broken Appointment Retraining Session
Write a Letter to the Dental Director
1. Why missed
2. Understand the impact
3. Promise never again
“Stronger” Consequences (Final Offense)Dismissal letter
30 days of emergency care access
Same-Day-Only Scheduling Status
Quick call lists
Patient required to call
Less Favorable ConsequencesCharging for No-Shows
Rarely works
Can’t charge Medicaid patients
Double-Booking Feast or famine
https://www.medicaid.gov/medicaid/benefits/downloads/policy-issues-in-the-delivery-of-dental-services.pdf (see question 11a)
Broken Appointment Best Practices
• A strong policy
• Consistent enforcement
• Scripting
• Same-day only
• Alerts
• Track
Minimizing the Risk of Broken Appointments
• 48 Hour reminder calls
• Multiple touchpoints
• Strategies for patients
you couldn’t reach
Minimizing the Risk of Broken Appointments
• Limit new patients
• Emergency patient F/U
• Multiple family members
• Limit how far out to schedule
15%
Why Manage Emergencies?
• Dental ER or Dental Home?
• Unpredictability
• Extra Work
• Reimbursement
• Disruption
• Patient/Staff Satisfaction
Quantify Demand
• Average Per Day
• Reality vs. Perception
• Tracking
When Demand Exceeds Capacity
• Patients of record
• Patients in service area
• Are all area safety nets doing their part?
Have A System In Place
• Where do emergencies fit?
• Who will provide care?
• What care will be provided?
• Morning huddle
Beware of Walk-ins
The Role of Triage
• What constitutes an emergency?
• Who decides?
• Objective criteria
Ask the Patient MUST BE SEEN
TODAY!See tomorrow or this
week
See when available
“On a scale of 1
to 10 how badly
are you hurting?”
Pain level 7 to 10 Pain level 4 to 6 Pain level 3 or below
“How long have
you been
hurting?”
This level for a
week or less This level of pain for a
month or less Had these symptoms for
over a month
“Describe the
type of pain or
discomfort you
feel.”
Throbbing Broken tooth, lost a filling Chip tooth, broken filling
“How are you
sleeping at
night?”
Keeps me awake
at night Able to sleep with
medication Able to sleep
“What occurred to
make the tooth
begin to hurt?”
Unknown or bit
down on
something hard
Bit down on something or
other cause Sweets; candy causes it to
hurt
“Have you
noticed any other
symptoms?”
Fever and
swelling ------ ------
Two or more
checkmarks in this
section results in the
patient needing to be
seen today
Three or more checkmarks in
this section results in the
patient needing an
appointment this week
Three or more checkmarks in
this section results in the patient
being given the next available
standard appointment time
Sample Triage FormPatient Name: ___________________________________ Date: _____________________Last Dental Visit: ________________________ Location of Pain: Bottom left, Bottom right, Top left, Top right________Patient Address: __________________________________ Contact Number: ____________________________________
Definitive vs. Palliative Care
• Definitive whenever possible
• Time
• Impact on BAs
• Patient/provider satisfaction
Have a Policy
• Define it all
• Share with staff
• Communicate to patients
Maximize Provider Productivity
Provider Productivity
• Too few encounters/day (although
sometimes too many)
• Too few procedures/encounter
• Missed opportunities
Common Factors Impacting Provider Productivity• Broken Appointments
• Scheduling
• DAs
• Goals/Accountability
• Personal Stuff
• Instruments, supplies
• Equipment issues
• EDR issues
Best Practices for Improving Provider Productivity• Decrease BAs• Improve scheduling efficiency• Hire more DAs (if understaffed)• Share goals and provide feedback• Consider an incentive program• Resolve instruments, supplies, equipment barriers• Staff training on EDR
Define the Scheduling Process• How far out to schedule?
• How many appointments at a time?
• How to use available operatories?
• Define appointment lengths for various procedures
• Who is needed when in each appointment?
• What visits can be double-booked?
• Start and end times each day
• Who can schedule appointments?
Scheduling Basics
• Ideal patient mix
• Available practice resources
• Hourly visit goals for each provider type
• Appropriate appointment lengths for various visit types
• Build and test the templates
• Use 10-minute increments if possible
Scheduling for Dentists• Minimum of two operatories and ideally two
assistants
• Staggered appointments in two columns
• Define workflow for each visit type
• Line up the blocks so the dentist’s time is maximized
• Consider each dentist’s individual characteristics but aim for standardization
Sample Template, DentistMORNING SCHEDULE: AFTERNOON SCHEDULE:
Time Op1 Op2Op3 (Overflow for
emergencies)
8:00 Emergency
8:10
8:20
8:30
8:40
8:50
9:00
9:10
9:20
9:30
9:40
9:50
10:00
10:10
10:20
10:30
10:40
10:50
11:00
11:10
11:20
11:30
11:40 Emergency
11:50 HOLD
12:00
12:10
12:20
12:30
12:40
12:50
Time Op1 Op2Op3 (Overflow for
emergencies)
1:00 Emergency
1:10
1:20
1:30
1:40
1:50
2:00
2:10
2:20
2:30
2:40
2:50
3:00
3:10
3:20
3:30
3:40
3:50
4:00
4:10
4:20
4:30
4:40 Emergency
4:50 HOLD
5:00
Intake10-minutes for medical hx review, blood pressure, etc.
Operative
40-minute appointments for Fillings/extractions. Can expand to 60 minutes for more procedures
Anesthesia
First 10 minutes of operative appointment, if anesthesia is provided, where the dentist might be available for a brief side-booked appointment (eg, denture try-in, suture removal) or to provide a POE or LOE
Lunch 30 minutes
Color Code:
Sample Dentist Template
MONDAY TUESDAY
Op 1 Op 2 Op 1 Op 2
8:00-8:15 planned care nonbillable Denture,
8:15-8:30 Initial Visit
8:30-8:45 planned care
8:45-9:00
9:00-9:15 planned care planned care
9:15-9:30 planned care
9:30-9:45 planned care
9:45-10:00
10:00-10:15 planned care planned care
10:15-10:30 planned care
10:30-11:00 planned care
11:00-11:15
11:15-11:30 planned care planned care
11:30-11:45 planned care
11:45-12:00 planned care
12:00-12:15
12:15-12:30 urgent care urgent care
12:30-12:45
12:45-1:00
1:00-1:15
1:15-1:30
1:30-1:45 LUNCH LUNCH
1:45-2:00
2:00-2:15 Nonbillable Nonbillable
2:15-2:30 Adult New Adult New2:30-2:45 planned care Patient Exam planned care Patient Exam
2:45-3:00 planned care planned care
3:00-3:15
3:15-3:30
3:30-3:45 planned care planned care
3:45-4:00 urgent care urgent care
4:00-4:15
4:15-4:30
4:30-4:45 END OF DAY WORK END OF DAY WORK
4:45-5:00
Another Sample Template, Dentist
Scheduling for Hygienists• Easiest schedules to fill; hardest to KEEP full!
• Broken appointments can wreak havoc
• Limit 6-month recall appointments
• Limit new patients in the daily schedule
• Double-book?
• Develop tasks for hygienists whose patients fail to show
• Generally only one column
Sample Hygiene Template
MONDAY 60-min block
8:00 AM New child 4-14
8:15 AM Recall Adult
8:30 AM SRP (1 quad)
8:45 AM
9:00 AM 45-min block
9:15 AM Recall child 4-14
9:30 AM
9:45 AM
10:00 AM 45-min block
10:15 AM New Adult
10:30 AM (exam in DDS column)
10:45 AM
11:00 AM 30-min block
11:15 AM Child <3
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PMLunch
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
Document the Scheduling Process• Create a formal scheduling policy
• Include scheduling templates as attachments
• Review the policy with entire staff
• Train staff how to use the templates
• Monitor, provide feedback and tweak as necessary
Common Scheduling Pitfalls• Scheduling out too far
• Multiple appointments
• Too many new patients
• Appointments lengths
• Misuse of provider time
• Double-booking
• Unused time
• Schedulers
Maximize Revenue
Billing and CollectionsWhy we leave money on the table:• Non-covered services• Non-covered patients• Failure to submit clean
claims• Flaws in billing process• Don’t collect from patients
Key Factors Impacting Billing/Collections
• Management of self-pay/SFDS patients
• Eligibility process
• Documentation
• Check-in/check-out
• Prior authorization process
• Revenue cycle processes
• Scripting
• Fees/SFDS
• Ongoing evaluation of performance
Billing/Collections Best Practices
• Closely monitor A/R past 90 days
• Scripting for front desk staff
• Formulate/sequence treatment plans
• Maintain insurance tables in EDR
• Faithfully document eligibility
Billing/Collections Best Practices
• Communicate clearly and accurately with patients
• Schedule appointments WHEN prior auths have been
approved
• Stay abreast of dental codes
• Review daily encounters for accuracy/completeness
• Morning Huddles• Regular Staff Meetings• Regular Meetings with
Executive Leadership
Creating a Culture of Accountability• Have a PLAN for success
• Monitor and analyze dental program performance
• Provide regular feedback to staff
• Get everyone at the table and engage them in establishing solutions and goals
• Reward success, coach setbacks
• Lead by example
• Make it fun!
Questions/Discussion