September 13, 2023
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH

Change for the Better: Are flawed processes keeping your team from experiencing better efficiency, healthier clients, happier employees, and continued practice growth?

Q: What’s your team’s billing IQ?

As a practice manager, I’m dealing with numerous human resource (HR) issues and client complaints related to hygiene billing. Some hygienists bill appropriately for the entire hour, while others only bill for part of the hour. There are also instances where hygienists bill for a full hour but spend the last 15 minutes on their phones or having coffee, resulting in the most client complaints and team conflicts. It’s clear that these billing issues erode client trust, but aligning the team has been challenging. There is always resistance and anger when attempting to discuss the matter.

The solution

Conflicts about hygiene billing are common and can be challenging to address for several reasons. Practice managers and owners often struggle to effectively converse with the hygiene team about billing because hygienists have their college to answer to and licenses to protect. This may create a breakdown in communication and cooperation. Let’s examine the reasons behind the most frequent billing breakdowns.

Breakdown No. 1: The hygienist is unsure who mandates your billing practices.

The hygienist is uncertain about the governing body that dictates billing practices. In a “traditional dental setting” (Dentist employer–hygienist employee), the dental associations develop and mandate billing practices for each province. On the other hand, if a hygienist operates as an “independent practitioner,” the dental hygiene association takes charge of billing regulations. Consequently, when questions about billing arise, the hygiene team should seek guidance and clarification from the dental and dental hygiene associations, depending on their practice setting.

What hygienists are aware of is the potential risk of having their licenses revoked by the college if they are found guilty of fraudulent billing by an insurance company, which is their primary concern.

Breakdown No. 2: Your province may bill a particular service differently.

The interpretation of procedures as either service-based or unit-based varies from province to province, creating differences in billing practices for hygienists. For instance, in most provinces, an exam, fluoride treatment, radiographs etc., are considered service-based, where the fee remains the same regardless of the time taken (i.e., to make it consistent). However, some unit-based services in one province may be considered service-based in another province. For example, “polishing” in British Columbia is regarded as a service-based procedure, where the fee remains constant regardless of the time taken. In other provinces, it may be considered a unit-based procedure, measured in half and full units. Some unit-based services like perio-evaluation may or may not be recognized in your province, and other unit-based services like desensitization and nutritional counselling may only be measured in full units and not half units. Hygienists must be aware of these provincial variations to navigate billing effectively, depending on where they practise.

Breakdown No. 3: The hygienist may wrongly be billing for “the hour.”

The billing method used by hygienists depends on whether they are in a consortium or non-consortium province. In consortium provinces like British Columbia, billing is typically based on the time scheduled, meaning if an hour is scheduled for debridement, the hygienist bills for an hour, i.e., four units of scaling. The scaling code in these provinces includes time to do assessments, documentation, client discussions, etc., so long as scaling is the predominant procedure.

In non-consortium provinces, the billing is based on “time on a tooth,” also known as “wet-handed billing.” This means the hygienist bills for the time they spend in the mouth performing services and unit-based procedures that are billable. The scaling code in these provinces only includes time scaling. For example, in an hour, they may bill 2 units for scaling, 1 unit for polish (if they spent 45 minutes performing those treatments) and exam (5 minutes) and use the remaining 10 minutes for non-billable procedures like assessments, documentation, client discussions, room setup and turnover.

Other provinces like Ontario and Alberta may be a blend of both. Hygienists must know the billing method applicable to their province of practise to ensure accurate and appropriate billing procedures.

Breakdown No. 4: The clinician may be making assumptions.

Ethical dilemmas surrounding billing usually stem from the clinician’s limiting beliefs about what the client values, what they are willing to pay for, and what insurance will cover. Instead of presenting the necessary treatment based on the client’s needs, some hygienists may provide recommendations based on these assumptions. Hygienists must be coached to deliver the required treatment without concern about insurance support. Doing so empowers clients to make informed decisions for themselves. This aligns with the codes of ethics, ensuring that the client’s best interests are prioritized over preconceived notions or financial considerations.

Breakdown No. 5: Your policies are vague.

Implementing systems and protocols to handle situations where team members spend time on the phone or take breaks during a client’s scheduled appointment is crucial. Suppose you don’t clearly establish, communicate, and enforce these rules. In that case, individual team members will fill the time as they see fit, creating liability and HR problems due to fraudulent billing and incomplete treatments.

Breakdown No. 6: There needs to be a common understanding.

When addressing billing issues, it’s essential to educate the entire team, not just the hygienists, about these potential breakdowns. To better understand billing practices, I recommend that team members read the “preamble” of each procedure in their provincial fee guide. This could be especially enlightening for clinicians who have not yet tapped into this invaluable resource, particularly if they frequently transition between different provinces. Also, each association provides many resources to their registrants to ensure billing acumen. They are always open to clarifying any billing. As a team, you make enquiries together and in writing, attend billing workshops and read articles written by the associations.

By providing comprehensive education and establishing clear guidelines, the practice can promote a unified approach to billing and ensure that all team members are well-informed and aligned with ethical billing practices.

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