Practice Support Team FAQs – X-Rays, Coding, & Billing

2017 Catalyst – Issue 3
By: Kathy Edwards, RDH, Margaret Boyce-Cooley, and Dana Morano of the Burkhart Practice Support Team

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We Can Do It! – Your Dental Assistant and CAD/CAM: A Powerful Combination

By Jennifer Blackburn, Practice Consultant, Burkhart Practice Support Team

The introduction of chairside CAD/CAM dentistry has expanded opportunities for the dental assistant and the dental practice as a whole.

Using digital technology, dental assistants now have a more vital role in all phases of the restorative process. They have the capability to streamline the schedule, free the doctor up to accommodate mid-appointment hygiene checks, increase production, and decrease overhead costs – all the while, increasing their involvement and job satisfaction.

Streamline the Schedule
Through the use of digital technology, the doctor and assistant are able to take advantage of breaks within each appointment to provide higher production treatment in both restorative ops by staggering the schedule. It also maximizes the patient experience and efficiencies and supports timing of hygiene evaluations to occur mid-appointment.

Imagine a schedule like the one to the right. The first patient arrives at 8:00 a.m. for a same-visit crown restoration. Anesthetic is administered, the assistant scans the opposing arch, captures the bite and selects the shade. By this time, the patient is numb and the doctor can prep the tooth.

It is now 8:30 a.m. and patient No. 2 arrives. The patient is seated and topical is placed while the doctor performs the exam on the patient in the hygiene room.

The assistant, after placing topical anesthetic, returns to the 8 a.m. patient to design* the crown restoration. This replaces the final impression and bite registration, saving the doctor time and the cost of impression materials.

It is now 8:45 a.m. and the doctor returns to approve the design and the assistant initiates milling while they begin the same process with patient No. 2.

Accommodate Mid-Appointment Hygiene Checks
Greater case acceptance results from the patient having time to process treatment recommendations and ask questions if necessary. By performing the hygiene exam mid-appointment, the patient has time to consider the treatment discussed and the hygienist has time to support the doctor’s recommendations. In addition, the front office now has time to prepare a financial plan for a smooth transition at the end of the appointment.

Increase Production
Having the assistant take on a larger role frees the doctor to do more productive and clinically intense procedures, in addition to treating another patient, consulting, or a hygiene check, without sacrificing precious time during the day.

Decrease Overhead
A dental assistant capturing images for orthodontic or restorative care procedures removes or limits the expense of impression trays, impression materials, temporary crown materials, lab fees and packing and shipping costs.

Increase Job Satisfaction
Empowering the dental assistant to more fully participate in all aspects of care provided by the practice leads to higher job satisfaction, increased motivation, improved employee retention and better patient care.

For more information about scheduling efficiencies, please reach out to the Burkhart Practice Support Team to request our Zone Scheduling Template. If you’d like more information about the bottom line impact of adding digital impressions to your practice, see page 6.

Thanks For Asking

By: Kathy Edwards, RDH, Margaret Boyce-Cooley and Dana Morano of the Practice Support Team


Burkhart’s Practice Support Team provides support to doctors by answering hundreds of questions that come in through our toll-free number and email. It is our pleasure to provide answers and resources—at no fee—to all of our Burkhart clients. Consider it a value-added service from Burkhart. We’ve compiled the most frequently asked questions and shared some insight on those here:

Q. What can you tell me about PPO fee negotiations?
A. It is critical to negotiate reasonable fees for your PPO participation. Fees can be negotiated at the time the contract is signed and every two years after that. There are several key strategies when negotiating fees with insurance companies, but the two listed here are a great place to start:
1. Evaluate your current fees. Evaluate your current UCR fees and make sure they are in the 75-85th percentile for your geographical area. It could be a wasted effort to attempt to negotiate if your current fee schedule is low for your area. You can contact your Burkhart Account Manager for resources to check your fees against other dentists in your zip code to determine your percentile. If you find your fees are low, it would benefit you to correct this situation prior to your negotiations.

2. Determine your leverage. There are some factors that gain more leverage when you enter negotiations. Take the time to determine if your practice can offer something that makes you more valuable as a provider for the insurance company. Some leverage points include:
a. Geographical location
b. Specialty offered, unique reputation
c. Availability in hours offered
d. Size of your practice (the larger the production, the better for negotiating fees)


Q. I went through Burkhart’s PracticeView Program last month and I wanted to get more clarification on what it means to “re-balance” my fees.
A. In addition to performing a 3-5% annual increase to your office (UCR) fees, we often find that the practice’s current fee schedule will need to be rebalanced. Having a balanced fee schedule ensures that all your fees are in a similar percentile that reflects the experience and technology you offer at your practice. Keep in mind that increasing all of your fees allows you more leverage to negotiate with PPO plans, allows higher reimbursement for out-of-network and dual coverage patients, keeps the fee schedules higher for your area as they are based on practice averages, AND ensures you get the highest reimbursement when plans update fees. It will be worth the extra effort to balance fees and, therefore, ensure you are getting the proper reimbursement for all procedures.


Q. I would love to drop all the PPO companies I’m contracted with but I know that may not be wise. How can I get a better handle on them?
A. There are a number of considerations when examining and managing your PPO participation:
• Are you billing full fees and adjusting off the difference?
• How many New Patients are you seeing per month? (count all 0150 and 0180s)
• Have you reviewed the percentage of New Patient flow coming from each PPO plan for the past 12 months?
Compile this data in a grid like the one below in order to develop a strategic approach to your participation. This data helps determine the true impact of each PPO contract administered by the practice. With this factual data, you can make a more informed decision for each individual contracted plan. Please email or call Practice Support Team and request the Excel spreadsheet to begin your analysis.


The Practice Support Team has years
of combined business and dental expertise!
Reach out to us today at no cost to you as a Burkhart account!

Bragging Rights! 5 Front Office Key Performance Indicators

Unlike the clinical team that is guided in large part by a detailed daily schedule of patients, the front office team must work directly with those same patients as well behind the scenes keeping the business of dentistry running smoothly. What indicators are available for the front office to brag about? We will highlight five key performance indicators that will allow the front office to evaluate their role and possibly hone in on systems within the practice that can support their personal achievement and the success of the practice.

1. Collections:
98% of Adjusted Production
If your monthly gross production (the sum of the fees you normally charge patients) is $85,000, and your monthly adjustments (courtesy and insurance writes offs) are $15,000, your total adjusted production is $70,000. Your collection goal would be $68,600 (70,000 x 0.98). If you are collecting less than the goal, look into systems for correction:

  • Emphasize with the team that every patient must check out with a front office team member and not duck out the door.
  • Ensure signed treatment plans are in place prior to treatment. Remind the team to use the “inform before you perform” rule to prevent treatment from being added on chairside that creates financial surprises for the patient and for you!

2. AR over 90 days: 5-10%
Aging AR should be closely monitored and managed. The odds of collecting balances after 90 days become slimmer, with less value on the return after you add in the overhead costs to make calls, send statements and track down overdue accounts.

Is your AR over 90 above the 5-10%?
Review these systems:

  • Are the outstanding balances from delayed insurance payments or the patient portion?
  • Are in-office finance options supporting balances in full
    within 90 days?
  • Do you collect credit card data and authorizations so you can run monthly charges?
  • Are clinical chart notes thorough enough to support narratives for quick insurance reimbursement?

3. Total Accounts Receivable: 3-4 Weeks of Production
Keep a close eye on the total accounts receivable-it should stay equal to 3-4 weeks of production. In other words, if you produce $100,000 per month, the total AR goal would be $75,000–$100,000. Why is this important to monitor? If AR is off, it can indicate a breakdown in several systems.

If it is too high:

  • Are the financial policies in the practice clear from the doctor?
  • Is the patient portion being collected at time of service?
  • Are the estimated patient portions incorrect or are patients seeing themselves out the door rather than having their appointments set complete by a front office team member?

If it’s too low:

  • Are the financial policies in the practice clear from the doctor?
  • Is the practice not offering outside funding options, or is treatment being recommended, but not scheduled, due to financial limitations by the patient? If this is the case, treatment presentation skills need to be honed.
  • Is a consult room being utilized and are good verbal skills from all staff members in place to uncover financial barriers in order to provide options to help patients get the treatment completed?

4. Recare Retention: 88%

Statistics show the average dental practice has an attrition rate of 12%. This would lead us to believe it would be reasonable to maintain an 88% retention of hygiene patients. The new patient flow needs to make up the difference for those losses and any additional growth the practice is targeting. Run a recare report to calculate the percentage of patients due vs. scheduled each month.

Below 88%? 

  • Remind clinicians to schedule chairside, if possible.
  • Review, perhaps “revamp,” the recare system. Hygienists can call overdue periodontal patients as they will be more successful in re-activation.
  • The recare coordinator should print reports and manage the system. The team needs to be involved in making calls and sending reminders.

5. Case Acceptance Rate: 80%
It’s not reasonable to assume the entire case acceptance for the practice falls on the shoulders of the front office team, but it is reasonable for them to track this number. A front office team member should be tracking the number of cases presented vs. scheduled every day. Keep in mind, it is considered scheduled if the next step is scheduled-not the entire treatment plan. When this percentage falls short, it should become a subject of the next staff meeting. There are a number of systems that feed this number:

  • Evaluate presentation skills:
    Make sure the exam is occurring early in the hygiene appointment
    to give the patient processing time, and the hygienist time to reinforce
    the diagnosis.
    Note: When patients are confused about treatment or ask clinical questions at the front desk-this is a key indicator something went wrong during presentation.

How did you rate? If you scored within the benchmark on all five topics, you deserve to brag a bit. If you identified some challenges within your systems-you still deserve to brag a bit as you can now be the conduit for change. The Practice Support Team is a no-fee consulting service for Burkhart’s clients, and we’d love to help you implement systems for greater business success.

Click here to see the original article.

Thanks for Asking

2014-04 PST 1

Kathy Edwards, RDH, Margaret Boyce-Cooley and Dana Morano of the Practice Support Team

Burkhart’s Practice Support Team provides support to doctors by answering hundreds of questions that come in through our toll free number and email. It is our pleasure to provide answers and resources—at no fee—to all of our Burkhart clients! Consider it a value-added service from Burkhart. We’ve compiled the most frequently asked questions and shared some insight on those here:

Q: How can I be sure I am hiring the right employee?
A: Hiring a new team member can be a daunting task, and it is difficult to “see through” that first impression. Fortunately, there are a few steps you can take to gain additional insight into a potential new staff member. Well-structured interview questions that focus on both technical skills and team interaction abilities through open-ended questions and scenarios force the candidate to provide more candid responses. If you find those answers satisfactory, the next step is a thorough reference check that needs to be done by the doctor directly. If the staff member will be handling monies and account information, a simple background check can help prevent disasters. We are happy to provide you with interview and reference check questions—give us a call or email the Practice Support Team.

Q: I am starting a new dental practice. is there any type of checklist you can provide to make sure I’m not missing anything?
A: Yes, there is—in fact, we not only have a checklist for dental start-up practices, but would love to be your resource! We have found that our start-up practice doctors not only appreciate the checklist, but find value in a phone call to discuss their specific concerns.

Q: My case acceptance rate could be higher. Do you have any tips I can pass on to my employees to increase the number of patients accepting treatment?
A: Your case acceptance is reliant on several things working well:
1. The transition from the RDH: Doctor engages the patient and includes a synopsis of the patient’s periodontal and restorative status, as well as aesthetic desires. The doctor’s exam should occur mid-way through the appointment, allowing the front office time to put together the financial part of the treatment plan, and time for the RDH to validate treatment once Doctor leaves the operatory.
2. For larger cases, a ballpark estimate given by the dentist will help the patient understand the type of investment they are making and potentially ask further treatment related questions.
3. The transition from the clinician to the front desk is done in front of the patient, so the next step in treatment is clear.
4. The front desk makes the plan affordable and gets it scheduled. They should be armed with phrases to use when patients don’t schedule, such as, “Are there any challenges I can help you with to get the needed treatment started?” All too often the patient has some type of challenge-usually financial-and they aren’t comfortable bringing up the topic. Knowing they can make a payment, or use an outside funding option, may be all they need. A private area to discuss this in is also highly effective!

Q: What is the difference between the two comprehensive exam codes (D0150 and D0180), and when is it appropriate to use one over the other?
A: Both codes can be used for comprehensive new patient exams. The D0180 includes a periodontal examination and is used for patients showing signs or symptoms of periodontal disease, or who have risk factors for the disease, generally an AAP III or higher case type. D0180 includes evaluation of periodontal conditions, comprehensive probing, and charting, evaluation, and recording of the patient’s dental and medical history. D0180 includes all the elements of a comprehensive restorative and periodontal exam, while the D0150 does not have the periodontal assessment requirement. For general dentistry practices that treat periodontal disease in-house, D0180 is appropriate for that patient base.

Offices should attach a higher fee to D0180 because of the extra time needed to conduct a full-mouth, six-point probing and recording for all teeth, plus charting of recession and mobility. Many third-party payers reflect a higher reimbursement in their schedules for this reason. Some offices alternate between D0120 for a regular preventive appointment and D0180 when a full-mouth periodontal charting is performed once a year. Remember, most third-party payers will cover two exams per year.

One of the frequent questions we hear is whether or not third-party payers will cover D0180. The answer depends on the payer. According to reports from some offices, payers will reimburse D0180 once every 12 or 24 months, some will down-code the D0180 code to D0120 for reimbursement, and a few will reimburse this code only once per lifetime. Insurance companies can set all kinds of restrictions on payment. It is important for practices to use appropriate codes to consistently reflect the work that has been performed, which is dictated by the patient’s needs, regardless of whether or not a patient’s third-party benefits cover the procedure.

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Prepare To Retire Well Before You Want to Retire!

By Margaret Boyce-Cooley
Director, Burkhart’s Practice Support Team


If you have even had a fleeting thought of retiring in the next ten years, don’t wait to prepare. We regularly hear from doctors that their one regret is not taking the steps they needed to early enough to ensure a smooth, financially rewarding transition for their practice. There is a great deal of preparation required before taking this big step. Failure to plan can create a lower value than you would like to get for your practice, or make it difficult to complete the transaction at all. Dental practices are in transition with regard to ownership; more corporate entities and DMSOs are emerging that will look critically at practice purchasing options. This is coupled with additional dental school graduates who will also be preparing for practice ownership. With this surge in the number of potential buyers comes an increase in the demand for quality practice acquisition opportunities.

What will make your practice more appealing to these unique buyers? Are you poised to take advantage of the marketplace in the next few years? Keep these twelve recommendations in mind as you consider your options:

1. Meet with your financial advisor. Can you afford to sell the practice? You need to be both financially and emotionally ready to sell.

2. Get your books in order. While you might understand them, someone coming in from the outside might not. If you don’t have an accountant, it may be time to hire someone to handle this task for you. All of the financial information surrounding your business needs to be in a format that is easy to understand; this way, your business can be easily valued, and interested buyers can see what they need to make a decision.

3. Discuss the tax impact of a practice sale with your accountant or financial planner. If you are a professional corporation, there are special considerations. Ask your accountant to project your after-tax picture once you are ready to sell.

4. If you have an associate, make sure you have a signed employment agreement that contains an enforceable restrictive covenant as well as a non-solicitation clause. Not having an agreement can negatively impact your practice’s value; if you don’t have one, consult an attorney for guidance.

5. Get a comprehensive practice valuation. Many brokers will credit the valuation fee to a future sales commission. Don’t just settle for a “ballpark” number derived from a mystical formula (production and collections for the past three years, multiplied by the number of active patients, divided by the middle number in your ADA license)-the fee charged for a professional, comprehensive valuation will be worth every penny.

6. It can be tempting to “coast” into retirement, but don’t let yourself slow down or work fewer days. Aggressively encourage new patients into the practice. Buyers are less inclined to buy practices that show a decrease in revenue over the last few years, especially in the pending market.

7. Active patient count and new patient flow are extremely important to buyers in evaluating the health and goodwill of a practice. We have heard that, on average, patients switch dentists every seven years. Therefore, an easy way to determine if your patient base is growing or declining is to divide your number of active patients (seen in recare in the past 18 months) by seven, and compare the result to the number of new patients you have seen in the past year. If the number of active patients leaving your practice each year is larger than the number of annual new patients, then your patient base is shrinking and should be evaluated further.

8. Assess your facility. Consider making some aesthetic enhancements if necessary. First impressions are important to patients and prospective buyers. Practices that do not have a positive “curb appeal” when buyers walk in the door can lose value and take longer to sell.

9. Because most buyers have been practicing for fewer than five years, they would prefer to utilize newer equipment and digital technologies in their practices. The practices that have digital radiography and chair-side computers tend to sell quicker and at a higher price than their counterparts. The more time you have until the practice sale, the easier it will be to get a sufficient return on investment from purchasing new equipment. We recommend that you upgrade your equipment three to five years prior to selling your practice.

10. Write off any uncollectible accounts and work to get the over 90 day Accounts Receivable down to 10% or less. If you don’t, this can become a tricky part of negotiations in the sale of the practice.

11. Consider fee increases. If your fees are well below average, increase them. Patients will accept the fee increase (despite what your team might think) and you will increase your income, as well as improve the value of the practice.

12. Cash flow is powerful in a practice sale. Start by ensuring that your major expense categories (staff payroll, dental supplies, and lab fees) are within industry norms. We have seen high staff overhead negatively impact practice sales. Next, make sure that you are doing everything possible to enhance practice revenue, increase case acceptance, attract new patients, and retain your existing patient base.

Clearly, there are many steps to be taken to ensure you get the most out of your practice transition. Planning is key! We encourage you to take a step toward assessing your practice’s readiness for transition with Burkhart’s Practice View service. Contact your account manager for details.

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