Manage ‘problem patients’ by using your ledger

“Mrs. Jones didn’t pay her bill again.”Dental Patient Complaints

“Mr. Johnson didn’t show up for his appointment.”

Problem patients – every dental practice has them. Patients that don’t pay their bills on time or at all. Patients that cancel appointments last minute or just plain don’t show up. Denture patients that come in 40 times for an adjustment. Ortho patients that constantly have broken brackets. These patients are a challenge to manage because they don’t flow smoothly through our recall and billing systems and their unique nature causes stress for staff that are required to deal with them.

To better manage problem patients, you need to recognize that they are a problem. This is most important in your collections process. The reality is that the patient who isn’t going to pay you, doesn’t tell you in advance, “Guess what? Once you save my hide by working me in for an emergency root canal, I’m not going to pay my portion after insurance!”

Track poor behavior in the ledger
To recognize problems, you need to identify the problem and then document it. You want to know when a patient doesn’t show up for an appointment. You want to know when a patient doesn’t pay their bill. First, decide what problems you want to track and then create a no fee ADA code with a description that clearly defines the problem.

Here are a few ideas:
• Cancelled appointment
• No show / Didn’t call
• Discussed missed appointments personally
• Outstanding balance
• Account sent to collection agency

No shows and Cancellations
For each of these codes, you need a system to consistently enter them for your patients. When a patient doesn’t come in for their appointment, what do you document in the chart? Do you put the patient’s name on a list to follow up and reschedule? You can add charge out the correct code to your routine as well. Then, when this same patient calls back in a few weeks and requests an evening or Saturday appointment, you can handle him appropriately.

One new change we added to our systems last year was “Discussed missed appointments personally”. In our practice, if the patient cancels or no-shows more than once, then our secretary team is expected to give “the speech” as it’s become known. “The speech” tells the patient that we’re sorry he missed his hour long appointment with Laura and we want to let him know that was wasted time for our professionals because we don’t double book our patients. We also say something about the biggest cause of fee increases is to make up for dentists and staff standing around when a patient doesn’t come in for their appointment. Finally, in our speech, we let the patient know that there is no charge today, but if they no show or cancel short notice in the future, then they will be charged.

Once we talk with a patient and give this speech, we charge out “Discussed missed appointments personally”. So, in this patient’s ledger you might see two instances of “No show” or “Cancel” and then a “Discussed missed appointments personally”.

Patients that don’t pay their bills
Similarly, we track patients who don’t pay for their dental care. We follow a standard collections procedure for any overdue balances and when we’ve made every attempt, the dentist decides to either write off the balance or send the account to collection. If we write off the balance, we mail a letter to the patient letting them know they have an outstanding balance and they will need to pay it off before any future visits. Then, we charge out “Outstanding balance” in their ledger. For accounts we send on to a collection agency, we also send a letter to the patient and then we charge out “Account sent to collection agency.

Every time you check out a patient, you’re looking at the ledger. When you have documented these financial poor behaviors, the office manager can quickly see what kind of patient they are dealing with. In our practice, secretaries are trained to offer a variety of financial arrangements options to patients. Even more importantly, they are trained not to offer certain types of financial arrangements when they see that a patient has had trouble paying us in the past.

Better management with senior staff
As you know, it takes a higher level of skill from a dental office manager to handle problem patients than it does to handle regular patients. Patients with these poor behaviors sometimes want to defend themselves and can become argumentative. This is difficult and stressful on new or less-trained office staff. Another benefit of tracking poor behaviors in the ledger is that you can know when your difficult patients are going to be checking out at the front desk – and you can arrange to have your highest trained dental office manager handling these patients.

Creating systems for your problem patients , and documenting them in the ledger, helps customize your patient care and reduces staff stress. Some patients will still complain, and to smoothly manage patient complaints takes a separate system altogether. Establishing the steps your team will take when one of these problem behavior occurs and then documenting the action taken solves problems quickly and efficiently.

Handling problem patients is just one way you can run a successful dental practice. If you’re interested in new ideas on running a dental practice, please subscribe to my weekly blog:

One of the biggest challenges to managing a dental practice is managing dental insurance. With dental insurance handled, then dental marketing for new patients becomes a primary focus. In today’s day of online reviews, handling patient complaints well is essential. As your practice grows, hiring dental staff becomes more important. With 16+ years of dental practice management experience, I’m open to your questions to help you run a successful dental office.

Feel free to email me.


AUTHOR: Jill Nesbitt
  • Mary Randall

    Good morning!

    Great article, but I wanted to give you a cause and effect with this type of entry. I am a certified Dentrix Trainer with Henry Schein. When you post a procedure code into the Dentrix ledger, it creates a last visit date in the Family File. So, if you use the last visit feature it may not be accurate if the last visit is actually a NO SHOW. My recommendation to offices is that they treat these fabulous tracking transactions as ADJUSTMENTS instead of PROCEDURES. They still track on the ledger, show on a statement, however are not tracked as a last visit.

    If a doctor wants a list of patients that he has not seen in the past two years, by using procedure codes, his list may not be accurate.

    I hope this info is helpful!

    February 28, 2013
    • Debbie Preece

      Great article, but if you charge for missed appts, and it is put in the ledger without being an adjustment it will add to the production totals for the day. I am out of adjustments to handle this except for a missed appt charge which I either charge or enter as $0. I agree with Mary Randall on this, it needs to be an adjustment, not a procedure.

      February 28, 2013
    • Mary – You’re absolutely right! Great idea to use the adjustment code. I will absolutely look into that. One question though – aren’t we limited to a certain number of + and – adjustments codes we can set up? Sounds like Debbie is already out of adjustments! We’ve always been hesitant to ‘spend’ one not knowing what we might need in the future. What’s your thought on running out of adjustment codes?

      Thanks so much for reading and taking the time to comment. All the best!

      March 2, 2013
  • Great article. Dentrix is one powerful program.


    February 28, 2013