Dental Program Redesign: Digging Deeper with DataDanielle Apostolon, Senior Project Manager, Safety Net Solutions

Junior Accountant, Computerized Bookkeeping, LLC

Accounts Payable Supervisor, W.B. Mason

Senior Project Manager, Safety Net Solutions, 2008-present

2

Danielle Apostolon, B.A. Business ManagementSenior Project Manager, Safety Net SolutionsDentaQuest Institute

Member, American Association of Public Health Dentistry

Associate Member, Association of State and Territorial Dental Directors

Member, National Network for Oral Health Access

Learning Objectives

Collect and organize key practice management data necessary to evaluate their dental program

Formulate realistic and achievable goals in the areas of access, finance and outcomes

Identify specific areas in need of a redesign using data

Medical

20% of clinic volume

80% of visits = varied

80% of visits = longer

80% of billing varied

80% of visits treatment

80 % of RVU different

0% of governance is designed around dental

EDR silo

Not familiar with dental model

Lack of confidence

80% of clinic volume

80% of visits = similar

80% of visits = shorter

80% of billing similar

80% of visits diagnostic

80% of RVU similar

100% of governance is designed around medical

EMR silo

Familiar with medical model

Confident leadership

Dental

Defining Capacity/Visits• We are limited by our structure

• Chairs-Rooms-Ops., Dentists, RDHs, DAs, Staff, Hours of Op

• Our structure determines our capacity not our hearts• We only have 20% of the capacity of Medicine• We cannot be everything to every patient of the CHC• Equitable, quality, care mandates that we work within

our capacity• We need to decide WHO gets the care• When we understand and define capacity we then

create our business plan

Defining Capacity/Visits, Cont.• Our patient population

– Serve primarily adults, children or a mix?

• Provider skill levels– Students/externs

– Recent graduates

– Advanced dentists

Our Program Goals are

My Goals are

My Role is

My Responsibilities are

Your Goals, Roles, and Responsibilities are

We need to get this done by

And… by the way:

THIS IS HOW WE ARE EVALUATED

Clarity

• Gross charges• Total expenses (direct and

indirect) • Net revenue (including all

sources of revenue)• Expense per visit• Revenue per visit• Aging report past 90 days• Payer and patient mix

• Number of visits • Number of unduplicated

patients• Number of new patients• Procedures by ADA code• Procedures per visit• Broken Appointment rate• Emergency rate

Key Data to Evaluate Program

Performance

• Percentage of completed treatments

• Percentage of children needing sealants who received sealants

• HRSA Sealant metric

Key Data to Evaluate Program

Performance, Continued

Clinic Data and Reports Needed

• Profit and Loss Statement

• Aging Report

• Transaction/Productivity by Procedure Report

• Payer Mix

• Collection Rate

• FTE’s/Provider Schedule

• Hours of operation

• Number of operatories

1300-1600 encounters/year/FTE hygienist

2500-3200 encounters/year/FTE dentist

2700 encounters/year with 1100 patient base/DMD

1.7 patients/houror 13.6 patients/day/dentist

Access=Visit Benchmarks

Benchmark Guide

Determining Capacity Goals Based on

Our Structure

# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

Potential Weekly Capacity = 135 Dentist Visits

Actual

Visits

% of

Capacity

Achieved

20 74%

26 96%

19 70%

18 66%

10 37%

*At least two operatories and 1.5 dental assistants

Setting Productivity/Access Goals: Visits Potential vs. Actual – FTE Dentists

# of

Providers

# of total

clinical hours

worked

x recommended

# of visits/

clinical hour

Potential

Daily Visit

Capacity

Mon. 1 8 1 8

Tues. 1 8 1 8

Wed. 1 8 1 8

Thurs 1 8 1 8

Fri 1 8 1 8

Potential Weekly Capacity = 40 Hygiene Visits

Actual

Visits

% of

Capacity

Achieved

7 87%

8 100%

6 75%

4 50%

6 75%

Setting Productivity/Access Goals: Visits

Potential vs. Actual – FTE Hygienists

GOAL CALCULATION TARGET

Visits/Day 27 Dental Visits + 8 Hygiene Visits = 35 visits per day *same for each day

35

Visits/Week 135 Dental Visits + 40 Hygiene visits = 175 visits per week

175

Visits/Year 175 weekly visits x 46 weeks = 8,050 Visits 8,050

Dental Visits Based on Capacity

Only fill in peach

colored cells Provider Type

General

Dentist A

General

Dentist B

General

Dentist C

Pediatric

Dentist Resident RDH A RDH B

Visit per Hour Benchmark 1.7 1.7 1.9 1

Daily Clinical Provider Hours 7 7 8 7 Monday 46 50 4

Visits 11.9 11.9 0 15.2 0 7 0

Daily Clinical Provider Hours 7 7 7 Tuesday 30.8 32 1.2

Visits 11.9 11.9 0 0 0 7 0

Daily Clinical Provider Hours 7 7 7 Wednesday 30.8 33 2.2

Visits 11.9 11.9 0 0 0 7 0

Daily Clinical Provider Hours 7 9 7 Thursday 34.2 35 0.8

Visits 11.9 15.3 0 0 0 7 0

Daily Clinical Provider Hours 7 7 7 Friday 30.8 32 1.2

Visits 11.9 11.9 0 0 0 7 0

Daily Clinical Provider Hours 4 4 Saturday 10.8 11 0.2

Visits 6.8 0 0 0 0 4 0

Weekly Visits per Provider 66.3 62.9 0 15.2 0 39 0 Weekly Visit Goal 183.4

Enter number of

weeks/year 46

Yearly Visit Goal 8436.4

Daily Provider Visit Goals Clinic Productivity Goals

Day of the Week Daily Visit Goal Actual Visits Variance

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Potential Weekly Capacity = 110 Dentist Visits

Model 1: 2 Dentists each working out of 2 Operatories with 1 dental assistant

Comparison

Model 2: 2 Dentists each working out of 2 Operatories with 1.5 dental assistant

Impact on Access

# of Providers

# of total clinical hours worked

x recommended # of visits/ clinical hour

Potential Daily Visit Capacity

Mon. 2 16 1.7 27

Tues. 2 16 1.7 27

Wed. 2 16 1.7 27

Thurs 2 16 1.7 27

Fri 2 16 1.7 27

# of Providers

# of total clinical hours worked

x recommended # of visits/ clinical hour

Potential Daily Visit Capacity

Mon. 2 16 1.4 22

Tues. 2 16 1.4 22

Wed. 2 16 1.4 22

Thurs 2 16 1.4 22

Fri 2 16 1.4 22

110 Visits per Week

135 Visits per Week

Cost Benefit

25 Additional Visits• 20% Self pay visits = 5 @ $40 =

$200 • 65% Medicaid visits = 17@ $135

= $2,295• 10% Commercial Insurance = 3

@ $165 = $495• 5% Homeless (Free Care) = $0

Total Revenue = $2,990

Salary

• $16/hour x 40 hrs. = $640/week

• Fringe benefits @ 25% = $160

• Total cost = $800/week

Cost of Providing Care

• 25 Visits x $10/visit=$250

Total Cost=$1,050

Cost vs. Benefit of Adding Dental

Assistant

Weekly profit = $1,940

Yearly profit = $108,680

Increases access by providing nearly 1,150 additional visits for the year!

Unduplicated Patients

Benchmark:

• 1,100-1,200 unduplicated patients per FTE General Dentist

• 2.5 visits/year per unduplicated dental patient

Calculation Target

Example 1 2 FTE Dentists x 1,100 2,200

Example 2 8,000 ÷ 2.5 3,312

Unduplicated Patients

Too Many:

• Overwhelming demand and trying to take care of too many patients

• Working out of our capacity

• Patients are unable to return for care to complete their treatment

Too Few

• Lack of demand and trouble filling the schedule

• Patients could be unhappy with the care

• Competition in the area

• Not enough patients to draw from (lack of needs assessment prior to opening)

New Patients

Number of new patients is measured by the number of comprehensive dental exams (D0150)

The number of new patients should equal the number of patients we completed treatment on

Need to determine the number of new patients the practice can manage

Too many or too few are both problematic

Access is everything associated with the visit:

VisitMeasures

• Services: Type – diagnostic, preventive, therapeutic, specialty

• How many services by ADA code?

• Safe-Equitable-Efficient-Effective-Timely-Patient Centric

• Financial Outcomes

• Charges for the services

• Revenue received for the charges

• Health & Oral Health Outcomes

• Quality of the services and of the customer service

• Compliance with Governance

AccessOutcomes

AccessNot Just Visits!

Dental Procedures

Benchmark for Procedures per Visit: 2.5

Total the number of procedures by ADA code and divide that by the total number of yearly visits

• Total annual visits = 3,600

• Total procedures by ADA/CDT code = 4,000

• 4,000/3,600 = 1.1 procedures per visit

Scope of ServiceBenchmarks

Service Type Procedure Codes % of Total

Diagnostic D0100-D0999 (excluding D0140)

35%

Preventive D1000-D1999 33%

Restorative D2000-D2999 20%

Specialty(endo/perio/prostho)

D3000-D6999 2-6%

Oral Surgery D7000-D7999 5-10%

Emergency D0140, D9110 2-6%

What Happens at the Visit

TimeProviders level of competency

Patient need

Patient tolerance

Reimbursement

Chaotic?

Measuring Dental Emergencies

• % of overall patient visits that were emergency visits during the reporting period

Total number of emergencies (CTD codes D0140 & D9110)

Total number of visits

The Problem – Broken Appointments:

• #1 cited problem for all safety net dental clinics

• 5 Key Areas Negatively Impacted:

Access to Care

Oral Health Outcomes

Staff Satisfaction

Patient Satisfaction

Financial Sustainability

Broken Appointments: Any time a patient misses or cancels a scheduled appointment, leaving insufficient time for the dental program to schedule another patient.

No-Shows:A patient is scheduled for an appointment and

they do not show up for that appointment.

Late

Cancellations:

A patient cancels an appointment less than 24

hours prior to the start of the appointment.

Late Arrivals:A patient does not arrive by 10 minutes after

the start of their appointment.

Measuring Broken Appointment

• % of all scheduled appointments that were broken appointments

Number of broken appointments

Total number of scheduled appointments

• Broken appointments= No-shows + late cancellations

• Scheduled appointments = Visits + No-show +last minute

cancellations – walk-ins

15% BA Rate

Balancing the Mission and Margin

Expenses Revenue

• Staff

• Cost Provide Care

• Overhead

• Visits

• Payer Mix

• Grants & Donations

Standardization Leads to Predictability

• Patient/Payer Mix

• 3rd Party insurance reimbursement

• Sliding fee discounts and nominal fees

• Visits

Predictability is Key

Financial Metrics

GROSS CHARGES

NET REVENUE

EXPENSES

ACCOUNTS RECIEVABLE

PAYER MIX

• Create a profit?

• Break even or zero variance?

• With grants or without grants?

• Willing to accept a loss? If so how much?

Define Financial Success

Calculating Net Revenue Goals

Goal Calculation Target

Revenue per Year Total direct and indirect expenses for the year= break-even; with grants

$800,000

Revenue per Week $800,000 ÷ 46 Weeks $17,391

Revenue per Day $800,000 ÷ 230 Days $3,478

Revenue per Visit $800,000 ÷ 8,050 Visits $99

Break-even with grants: Total expenses

of $1,050,000- $250,000 in grants =

$800,000

Benchmark

• $450,000-$550,000 per year per FTE Dentist

• $250,000-$350,000 per year per FTE Hygienist

Calculating Gross Charges Goals

Goal Calculation Target

2 FTE Dentists 2 x $550,000 $1,100,000

1 FTE Hygienists 1 x $350,000 $350,000

Gross Charges per Year $1,350,000 $1,450,000

Gross Charges per Week

$1,350,000 ÷ 46 Weeks $29,348

Gross Charges per Day $1,350,000 ÷ 230 Days $5,870

Gross Charges per Visit $1,350,000 ÷ 8,050 Visits $168

Individual Production Goals

Provider FTE Gross Charges

Net Revenue (60%)

Annual Days Worked

Charges/Day

Revenue/Day

Dr. A 1.0 $550,000 $330,000 230 $2,391 $1,435

Dr. B 1.0 $550,000 $330,000 230 $2,391 $1,435

Total Dentist 2.0 $1,100,000 $660,000 460 $4,782 $2,870

Hygienist A 1.0 $350,000 $210,000 230 $1,522 $913

Total Hygienist

1.0 $350,000 $210,000 230 $1,522 $913

Overall Clinic Goals

$1,450,000 $870,000 230 $6,304 $3,783

Common Factors Impacting Finance

Productivity Busters: Empty chairs = missed opportunities

Reimbursement environment:

Low encounter rate or fee for

service

Issues in the billing &

collections process

Fee schedule & SFDS/Nominal fee: Fees below

market rate, nominal fee too

low

Patient/Payer Mix: high

number of uninsured adult

patients

Payer Mix

• Huge impact on financial sustainability

• Big challenge to manage

• Determine the average revenue per visit per payer type

• Use that information to create a payer mix that ensures financial sustainability while preserving access for all patients

Impact of Payer Mix on Sustainability

7,500 visits

35% Medicaid =2,625 visits x $100 = $262,500

55% Self-Pay/SFS =4,125 visits x $30 = $123,750

10% Commercial =750 visits x $125 = $93,750

Total revenue = $480,000

Total expenses = $500,000

Operating loss = ($20,000)

7,500 visits

40% Medicaid =3,000 visits x 100 = $300,000

50% Self-Pay/SFS =3,750 visits x $30 = $112,500

10% Commercial=750 visits x $125 = $93,750

Total revenue = $506,250

Total expenses = $500,000

Operating surplus = $6,250

Average Reimbursement by Payer Type

Financial Projections Projected Visits

Actual Visits

Difference -6500

Patient/Insurance mix: Yearly visits

Percent Medicaid -

Percent Self Pay -

Percent Commercial Insurance -

Percent Other -

Total 0% -

Reimbursement Rate (per visit): Yearly Revenue

Medicaid -$

Self Pay -$

Commercial Insurance -$

Other -$

Total Projected Revenue -$

Total Expenses

Projected Bottom Line -$

Payer Mix Tool

Payer Mix

• Designate public health and/or medically indicated priority populations and work to get them into the practice

• Pregnant women and children are two populations more likely to have insurance coverage

• Goal to preserve as much access for uninsured patients as possible while maintaining financial sustainability

• Being financially sustainable lays the groundwork for expansion, which increases access for all payer types

• Use data and knowledge of the practice to inform decisions around patient and payer mix!

Sample Template (morning session, one dentist

and two hygienists)—Daily Net Revenue Goal of $4,131

Time Operatory 1-

DDS

Operatory 2-

DDS

Operatory 3—

RDH1

Operatory 4—

RDH2

8:00 Emergency ($50) Adult new ($50) Adult new ($50)

8:30 Priority TX

($140)

9:00 TX ($140) Priority Recall

($140)

Priority recall,

($140)

9:30 Priority TX

($140)

Priority recall

($100)

10:00 TX ($200) Priority Recall

($140)

Priority Recall

($140)

10:30 Emergency

($140)

Priority Recall

($140)

Perio ($100)

11:00 Priority TX

($140)

Priority Recall

($140)

Designated Access Scheduling Template (afternoon session, one dentist and two hygienists)

Time Operatory 1--

DDS

Operatory 2--

DDS

Operatory 3-

RDH1

Operatory 4—

RDH2

1:00 Emergency ($50) Denture interim

($0)

Adult new ($50) Priority new

($140)

1:30 Priority TX

($140)

2:00 Denture interim

($140)

Priority Recall

($140)

Priority recall

($140)

2:30 Priority TX

($140)

Adult recall

($100)

3:00 TX ($140) Priority Recall

($140)

3:30 Priority TX

($140)

Adult Recall

($140)

Priority recall

($140)

4:00 Emergency

($140)

Priority Recall

($140)

Adult recall ($50)

Billing & Collections

• Amount of money owed to the practice past 90 days from self-pay patients

• % Collection rate for self pay visits

• Accounts Receivable past 90 Days

• Number of Denied Claims

When Billing and Collections Goes Wrong….

• $886,229 Self-Pay

• $654,663 Medicaid

• $102,461 Medicaid Managed Care

• $48,564 Commercial

• Total = $1,691,917

Billing/Collections Best Practices

• Keep a close eye on A/R past 90 days and denials to quickly spot and respond to any negative trends

• Use scripting to help staff educate patients about why payment is required at the time of service

• Make sure providers formulate and sequence all patients’ treatment plans (essential building block of success)

• Make sure insurance tables are built into the EDR (even if billing out of the EHR), including all SFDS categories

• Document patient eligibility when appointment is scheduled and again a couple of days before the appointment

Checklist to Dental Redesign

Define What Success Should Look Like in Dental

Gather Data that is accurate, timely and meaningful

Compute and Understand your actual Capacity

Set Clear Goals, Roles and Timelines for both the Dental Team as a whole and Individuals in : Access, Finance and Outcomes

Have a policy for “Everything”!!!!

Set fees at the usual and customary of the market rate in your service area

Execute a Quality Management System including CQI and QA in Dental and in the CHC

Create a Dental Culture of Accountability

Actively Manage: Broken Appointments/Last Minute Cancellations; Self Pay Patients; Front Desk; Payer Mix ; Customer Service; Billing; Emergencies; Priority Populations; Scope of Service

Use the Dental Schedule Strategically!

Know what your own Leadership should look and feel like to best enable/support Dental

Checklist to Dental Redesign

SNS Technical Assistance Resources

• Dental Policy & Procedure Manual Template

• Sample Clinical Protocols

• Sample Dental Job Descriptions

• Sample Broken Appointment Policies

• Scripting for CHC Dental Staff

• Profit & Loss Budget Variance Tool

• Financial and Productivity Goals Tool

• Payer Mix Projection Tool

• Dental Program Performance Tracking Tool

• Productivity Benchmark Guide

• Sample Scheduling Policy

• Sample Emergency Policy

• Sample Quality Assurance Policy

• And much, much more!

Link to Access Resources:

• https://www.dentaquestinstitute.org/learn/online-learning-center/resource-library

• (https://www.dentaquestinstitute.org/learn/online-learning-center/online-courseware/safety-net-dental-practice-management-series) – Developing Billing Excellence– Fee Schedules, Sliding Fee Scales, & Management of the Self-

Pay Patient– Safety Net Dental Program Finance and Productivity: Your

Mission and Your Margins– Front Desk Customer Service– The Front Desk: Creating Your Dream Team– Managing Chaos in the Dental Program– Scheduling by Design

FREE CEUs Available!

SNS Online Practice Management Series

Partnering to Strengthen and Preserve

the Oral Health Safety Net

2400 Computer Drive, Westborough, MA 01581 Tel: 508-329-2280 Fax: 508-329-2285 www.dentaquestinstitute.org

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