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The Importance of Informed Refusal Forms
Marianne Harper

Are you dotting all of the I's and crossing all of the T's in your practice? I am always impressed with how well run many dental practices are that I work with. Even the most well run practices may be missing the mark in one area – informed refusal of treatment. Do you offer your patients a form that a he or she signs that indicates that he or she is refusing treatment? If not, please consider the importance of such a form.

Each of your patients has the right to accept or refuse recommended treatment. Informed consent is routinely obtained in many dental practices but the informed refusal of treatment does not appear to be as consistently used. Dental teams spend a good deal of time verbally advising patients of the benefits of certain treatments and the potential risks of non-treatment. There are very important legal safeguards in using informed refusal of treatment forms with these patients and some insurance carriers even recommend using them. By detailing the possible consequences of non-treatment in writing, patients may better realize the seriousness of non-treatment.

An informed refusal of treatment form can be similar to your informed consent form but instead of the form stating that the patient will undergo a certain dental treatment it will state that the patient has refused the treatment. The following should be included on the form:
What the doctor told the patient about his or her condition and why the treatment is necessary.
Any possible risks and consequences of non-treatment.
Indicate if a patient refuses to see a specialist that the dentist has referred him or her to and list the possible risks of not seeing the specialist.
The form should then be signed and dated by the patient and a witness should also sign and date it. A copy of this form can be given to the patient. The original form can be either scanned into the patient's record or kept in the patient's chart.

Such a form that clearly states what the dentist's plan of care would have been and what the potential consequences of non-treatment might be should be implemented in all dental practices. With such a form a patient cannot say that he or she did not understand. Rather than simply documenting in the patient's record the verbal communications with the patient, protect your practice by using informed refusal of treatment forms.

Informed consent forms, just as the informed refusal forms, should be implemented in today's dental practices. I have created some consent forms for different procedures. If you would like a free copy of any of these consent forms for: dental x-rays; nonsurgical periodontal therapy; crowns, bridges and dentures, or smile makeover, please email Colleen at
Employ a Medical Model and Increase Hygiene Department Profitability
Colleen Rutledge, RDH
A repeat article from a 2011 newsletter, but a message worth repeating

When interviewing a new client, the majority of offices describe what I call a “mechanical model”, which means the focus of the perio therapy is on removing calculus one or two quadrants at a time. This approach usually fails, as after completing one or two quadrants, many patients do not complete their treatment. A year later you see them again and the treated quadrants are re-infected by bacteria from the untreated quadrants. Sadly, the patient is back to square one.

My recommended approach is using a “medical model” which is focused on decreasing the bacterial load in the entire mouth with treatment completed within 24 - 48 hours. Although longer appointments are necessary, proper use of ultrasonics increases efficiency, utilizing one or two one and one half hour appointments rather than four one hour appointments. The incorporation of locally applied antimicrobials during initial therapy as well as maintenance enhances clinical outcomes and substantially augments the services and profitability of the hygiene department. Utilizing the “medical model” easily transforms hygiene departments from “loss leaders”, producing $800 - $900 daily, to “production leaders” achieving $2500 or more when employing a comprehensive periodontal therapy program. Practices offering services based on current research and trends in periodontal therapy see hourly production rates soar from $90 - $120 to $150 - $400, with the average patient producing $ 400 - $700 or more. Embracing this model, hygiene departments can flourish into indispensable channels of both quality and profitability!

10% OFF SALE on every product in our store until November 15, 2013! Use code OCT13 at checkout. Please visit to shop now!
  Insurance Alert
Dental – 2013 is quickly drawing to a close. With that come changes to the CDT codes. The 2014 codes will contain three new subcategories, 29 new codes, and 4 deleted codes. To prevent delays in payment and denials, you must make these changes in your software. Make your insurance system as efficient as possible by obtaining the 2014 codes. My recommendation for the BEST source of codes and coding help is both "Coding with Confidence" and a subscription to "Insurance Solutions Newsletter." To order "Coding with Confidence" download the Coding with Confidence Manual Order Form. To subscribe to the "Insurance Solutions Newsletter" download the Insurance Solutions Newsletter Order Form.
Medical – Last month's newsletter touched upon the changes to the CMS-1500 form. Dates have now been established for implementation:
January 6, 2014 – Payers will begin accepting claims submitted on the 02/12 CMS-1500 form
January 6 through March 31, 2014 – Dual use period for both forms
April 1, 2014 – The 08/05 version of the CMS-1500 form will no longer be accepted by carriers and only the 02/12 version will be accepted
You will need to check with your software vendor(s) to be sure that they are prepared for these dates.
  Time Line
October 1, 2013 – This is the date for medical diagnosis codes to update. However, due to the impending change to ICD-10 in 2014, the only changes to the diagnosis code set deal with new technologies and diseases. Therefore, for purchasers of "CrossWalking – A Guide Through the CrossWalk of Dental to Medical Coding", there will be no update this year. I will notify you in December about the CPT code update.
September 23, 2013 - HIPAA Omnibus Final Rule – The updates to this rule were published on January 25, 2013. The compliance date is September 23, 2013.
January 1, 2013 – Updated CDT and CPT code sets
April 1, 2014 – All medical claims must be submitted on the 02/12 version of the CMS-1500 form.
October 1, 2014 – The new date for ICD-10 implementation.

Favorite Quotes:
"True ignorance is not the absence of knowledge, but the refusal to acquire it."
– Karl Popper

According to an article in the August 2013 issue of Sunstar, E Briefs – News You Can Use, there is an evidence base that probiotics can promote oral health. It states that researchers believe probiotics can offer a noninvasive natural defense against pathogenic bacteria. So share this information with your patients.

Points of Interest:
Halloween is just about upon us. Here are some pretty useless but hopefully interesting facts about Halloween:
Halloween is thought to have originated around 4000 B.C., which means Halloween has been around for over 6,000 years.
The first Jack O'Lanterns were actually made from turnips.
Halloween is the second highest grossing commercial holiday after Christmas.
According to Irish legend, Jack O'Lanterns are named after a stingy man named Jack who, because he tricked the devil several times, was forbidden entrance into both heaven and hell. He was condemned to wander the Earth, waving his lantern to lead people away from their paths.
Trick-or-treating evolved from the ancient Celtic tradition of putting out treats and food to placate spirits who roamed the streets at Samhain, a sacred festival that marked the end of the Celtic calendar year.
"Halloween" is short for "Hallows' Eve" or "Hallows' Evening," which was the evening before All Hallows' (sanctified or holy) Day or Hallowmas on November 1. In an effort to convert pagans, the Christian church decided that Hallowmas or All Saints' Day (November 1) and All Souls' Day (November 2) should assimilate sacred pagan holidays that fell on or around October 31.
Black and orange are typically associated with Halloween. Orange is a symbol of strength and endurance and, along with brown and gold, stands for the harvest and autumn. Black is typically a symbol of death and darkness and acts as a reminder that Halloween once was a festival that marked the boundaries between life and death.
Ireland is typically believed to be the birthplace of Halloween.
According to tradition, if a person wears his or her clothes inside out and then walks backwards on Halloween, he or she will see a witch at midnight.
Dressing up as ghouls and other spooks originated from the ancient Celtic tradition of townspeople disguising themselves as demons and spirits. The Celts believed that disguising themselves this way would allow them to escape the notice of the real spirits wandering the streets during Samhain.

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The Art of Practice Management
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