fundamentals - d4 practice solutions

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

doribingham@d4dimension.com

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

D4 Practice Solutions

My Cell: (508) 776-1826

doribingham@d4dimension.com

www.d4practicesolutions.com