Blind Spots: When a patient refuses nonelective treatment

What does your practice do when a patient refuses treatment, particularly nonelective (mandatory) treatment?

Before we begin to discuss this important issue, let's define elective versus nonelective treatment. For the sake of this article, treatment in the mandatory category involves infection, pain, discomfort, decay, bleeding gums, fractured teeth, jaw joint dysfunction, and potentially life-threatening oral lesions. Elective treatment, on the other hand, includes treatment to improve aesthetics and function, such as bleaching, porcelain veneers, placement of sealants, and other preventive measures, as well as implants, crowns, bridges, and dentures. Our main focus is on mandatory treatment, but a system to deal with refusal of elective treatment is important, too. (See more, below.)

Jan Keller.

So what happens when a patient in your practice refuses mandatory treatment? Having a strong system in place to follow up with a situation like this is a blind spot in many dental practices.

Many times, when patients say "No," they mean "Not today," but that does not mean "never." If we understand our patients' wants, what their hot buttons are, and what their current life situation is (that is, other significant expenses such as kids in college, graduation, weddings, and travel), the approach we take can assure them we understand what is happening in their life.

Our goal is to make sure they understand the benefits of the treatment, as well as working with them on scheduling and financial decision-making. If the treatment is elective, keep in mind that research has shown that the buying cycle for elective dentistry is six months.

If patients choose to delay treatment or not move forward, your next step should be to have them sign a Refusal to Consent to Treatment letter that explains the treatment prescribed, the benefits to the treatment, and what can happen if treatment is delayed.

In my experience, when patients are presented with a refusal of treatment statement, which includes an acknowledgement that they refused treatment, many will change their mind about treatment. This is a choice. When patients are confronted with having to sign for their choice to not proceed, a typical response is, "Oh, I didn't know it was that important or urgent." When this happens, it's an indication that the clinical team did not fulfill their responsibility of getting the patient "buy-in" before handing them over to the financial coordinator -- another blind spot in dentistry we will discuss in a future article.

(Note: When they do agree to treatment, do not allow patients to leave without signing the consent form, signing the financial documentation, and scheduling the treatment.)

Documentation is critical. How many times has a patient said to you or your staff, "I did not know" or "I was not told I needed that," even though you have it documented in your clinical notes. This is why you need to have patients sign a form that they had the treatment explained, what their decision was, and why they refused treatment.

Another critical component is the system you have in place to follow up with the patient who refused treatment. Do you have one? Do you know how much treatment in the month of June you presented to patients, how much was scheduled (that is, what is your success rate?), and the reasons for delayed treatment? A system should be in place to track and follow up with the patient who is delaying treatment.

Without having this system in place, the practice will lose opportunities, and the patient will think it is not important or necessary. It is also important from the business side of the practice to know how much treatment has been diagnosed and presented, as well as how much has been accepted, scheduled, and paid for. The numbers can show trends and how well you are doing with your treatment presentation, while answering questions such as, "Where are we falling down?" and "What part of our treatment presentation system needs tweaking?"

The systems can also protect the doctor and the practice from future liability. If patients who have refused treatment go to another dentist with the same or worsening issue, they cannot claim ignorance as to their situation ("My previous dentist never told me I had a problem.").

Elective treatment can be handled differently, as the timing simply might not be right, but having a clear system in place to track the number of treatments presented, diagnosed, accepted, scheduled, reason for delay (if any), and how the team is going to follow up with this is important.

This should be one of the primary roles for your treatment coordinator, shared with your office's scheduling coordinator and financial coordinator, depending on your particular setup. Having a set of guidelines for negotiating payments is a separate topic to be addressed in a later Blind Spots column.

Here is wording that should be included in refusal of treatment documents:

Treatment presented by (Name of Doctor) to (Name of Patient), alternate treatment, treatment risks, and risks if treatment is not done.

Having received a full explanation of the proposed treatment, alternative treatment, risks, and risks if no treatment, I have elected to receive NO TREATMENT at this time. By signing below, I acknowledge that I have read this document, understand the information presented, have had all my questions answered satisfactorily, and I accept the risks and responsibility for the NO TREATMENT option I have elected.

The patient and the treatment coordinator sign and date the document, which is then stored in the patient's electronic or paper chart.

Jan Keller has more than 25 years of experience in dentistry as an office manager and a software trainer. Now, as a practice management consultant, she provides customized practice development and education to clients and their teams. She is certified by Bent Ericksen & Associates in employee law compliance and also by the Practice Management Institute.

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