Dental Fees FAQ.

Or: I can get it for you wholesale...

With the possible exception of fear of pain, the topic most fraught with anxiety on the part of the patient is the cost of health care.

Q: Can any one give me some hint how much is one crown for a root-canalled tooth? And what about ceramic material?

A: Fees can vary widely depending on the region and the affluence of the locality where services are provided. Here in Brooklyn, NY, our fee is around $600, not including any post and core build up, which may be necessary if root canal treatment has been performed (that's an additional $125). We have seen fees in Manhattan well over $1000.

As you can see, there is tremendous variation right here within the New York City limits. The Federal Trade Commission is not happy about dentists sharing data regarding their fees (some kind of price-fixing restraint of trade nonsense), so acquiring this information will take some investigation.

By the way, most dentists instinctively resent "shoppers", but you're entirely within your rights to ask about fees. Keep in mind, though, that if you find a dental office where "the price is right", the dentist may decide that a different treatment is appropriate, and the price quote will go right out the window. There is no one "right" treatment.

Q: WHY ARE THE RATES FOR CROWNS SO HIGH AND ESPECIALLY IF YOU HAVE INSURANCE THIS LITTLE CROWN ON TOOTH 29 IS COSTING $721.00 AND I WAS TOLD IT WOULD BE HIGHER NEXT YEAR. I AM NOT CHEAP BUT THIS SOUNDS VERY HIGH. THANK YOU...THE INSURANCE DOESN'T COVER EVEN HALF.....

A: All we can say is that Alan Greenspan is wrong when he says there is no inflation!

Dental fees are set by charging an amount that will provide fair compensation for a dentist's services after expenses. Whether you feel it's a fair fee will depend on the value you place on your oral health. These fees are subject to the same market forces of supply and demand that effect every other service or product.

Our fee for a ceramo-metal crown is $600, but we're in a very competitive market in Brooklyn, NY, and a substantial part of our clientele are working class blue-collar union members. In more upscale areas the charge is higher; in some indigent areas the fee may be lower.

We usually infer from a patient's unwillingness to accept a reasonable fee as a sign of his lack of recognition of value in a dentist's service. We've had patients protest that there was less than 50 cents worth of silver in their $75 filling; these same people have no problem paying $125 to their hairdresser. It's all a matter of where your values are. You can probably take solace in the fact that if your car was in the shop for as long as your tooth will be, it would cost you more than $721.

That your insurance pays less than half the fee is not unexpected; a common benefit structure would be 50% after an annual deductible. Be happy you have dental insurance at all; many employers are dropping the benefit for their employees, as it is becoming increasingly viewed as an expensive extravagance...

Q: I went to my dentist for a "cleaning and exam"...$85. No problem. When I leave, he charged me $125. He said it was because he had to take a couple of extra x-rays because of my wisdom teeth. Do you think a patient should have to pay for anything other than what he asked for? I think he should have told me there would be an extra charge for the x-rays before he took them so I could make the decision of whether or not I wanted them. It really ticks me off when dentists do procedures in addition to what you asked for when you made the appointment, and then charges you for them. I think it's a rip-off. How can anyone keep their budget in order when liberties like that are taken without your approval? It's not like I was in the chair unconscious? Any thoughts?..Thanks.

A: We feel your pain. We just went to the auto mechanic for a state inspection and came out with a new exhaust system...

Let us tell you something about dentists and money. We don't feel comfortable discussing it. That's why we hire Godzilla for the front desk, so she can handle it while we hide in the back. When a patient comes in, we sometimes don't know what was discussed at the front desk. Sometimes our receptionist has quoted a fee; sometimes not. We're convinced that patients are as uncomfortable with this issue as we are.

We do not confer with our receptionist regarding how to do our dentistry, so it's inappropriate for her to promise a particular fee (she sometimes does it anyway). Sometimes the lines of communication are not open. It happens. We seldom have patients discuss fees with us while they're in the chair. If the topic comes up and we quote a fee, we make sure to let the patient know if our discretion indicates the need for services that will incur additional charges.

When a service is rendered, there is an implied contract that a patient will pay associated fees, regardless of what they are. If a patient is concerned about the fee, he must raise the issue before charges are incurred, otherwise, by giving consent to treatment, he is giving tacit approval of the associated fees. If the specifics of the fees are discussed, the contract goes from being implied to being expressed. If you had an expressed arrangement of fees prior to treatment, the doctor must get expressed consent from the patient prior to making additional charges.

If the events are as you represented, the doctor has breached the contract. He must realize the additional $40 he is charging is far less than the value of the good will he is sacrificing by not forgiving the unexpected fee.

Q: Can someone please tell me the answer to these three questions; I am a newly graduated dentist.

  1. When a patient comes to your office and makes a full mouth exam how do you introduce the payment to him and how much money will it cost? Do you give him an estimate right away or you simply get to work and let him find that out later.
  2. What happens when the client is out of the door, has paid let's say half of the amount he is supposed to and when refuses to pay the other half saying that he's been had by you guys. If he starts to argue but still don't want to pay what do you do?
  3. Lets say you guys make a set of dentures for someone and it is a middle-aged woman who you cannot detect that she will give you a hassle about the dentures later on. After the dentures have been inserted and fee paid she comes back latter on and says she doesn't like the dentures and that they don't fit right (could be her mental problem) and she is really persistent to get her money back without legitimate evidence to support that. Do you give her the money back or no. How about you make every client sign a legal document or paper that you just made up yourself saying that in case she cannot get adjusted to dentures or changes her mind later on that you can only give her 50% of the money back and the other 50% you keep for your time and effort. If she doesn't sign then you cannot go with the treatment and refer her to someone else. Is this legal?

A: Disclaimer: We are not, nor do we profess to be attorneys or legal experts. Some of the answers to your questions are a matter of personal style, but some turn on matters of legal consideration that lie beyond our field of expertise. In such cases, our answers rely on our personal understanding, which may or may not be relevant in your case. For authoritative answers, you should contact your own attorney.

There are three relevant considerations in the situations you pose:

  • It is a fairly well accepted fact that health care practitioners have certain obligations to their patients. The failure to honor those obligations may constitute professional negligence, which may open the doctor to claims of malpractice if damage results from that negligence. What is sometimes not readily grasped is that patients also have obligations to their doctors: payment of fees, keeping of appointments, following professional direction, and the like. The specific mutual obligations are part of contract law, and the default of either party to these provisions is a breach of contract, which justifies severance of the doctor-patient relationship. It may also expose either party in default of that contract to damages.
  • Just how a party to this relationship responds to a breach of another party to the contract is largely a matter of personal discretion. A victim of malpractice may choose not to litigate; a health care provider may choose not to aggressively pursue the collection of unpaid fees. There is no obligation one way or another.
  • People sometimes retaliate in one way or another after being accused of breach of contract, regardless of whether they are in the right or wrong. Statistics show that a doctor's aggressive collection of unpaid fees is the number one factor in the initiation of malpractice claims.

The questions you ask do not depend on a dentist's right to aggressively pursue the collection of unpaid fees, which is beyond argument, but rather on whether the dentist feels the effort and risk of collection is justified by the amount of money involved. The collection process is not necessarily pleasant, even if it is handled by a third-party collection agency. Depending on the amount of money involved and the temperament of the doctor and patient, it sometimes makes more sense to write off the uncollected fees as bad debt.

As to your questions...

  1. You should always have your front desk staff inform the patient in advance the fees he will incur. Discussing money in the operatory is inappropriate, and it places the dentist in a mercenary light. Let your receptionist do the dirty work. There's no need to be shy about telling the patient the fee-- you can bet he wants to know. Although a patient gives de facto approval to the fee (regardless of whether he knows what it is) when he sits in the operatory chair, it's just cleaner all around if he has a chance to object before he is charged.
  2. As we stated previously, this is a matter of style. It makes good sense to make a few gentlemanly attempts at collection yourself before turning it over to a collection agency (they usually claim one third to one half of any amount collected). Sometimes the amount can be negotiated (for example, having the patient pay only the lab fee), as a small concession to mollify a patient who has legitimate complaints. After all, sometimes a patient's dissatisfaction is our fault. If a patient is truly belligerent and is intent on teaching you a lesson, don't waste your time. Either turn it over to an agency or use the bad debt as a write-off.
  3. It is certainly your prerogative to set the financial ground rules prior to beginning treatment. If you want to ask your patient to sign such an agreement prior to treatment, there is no legal reason why you couldn't. The problem with such a practice is that it sets a somewhat confrontational tone from the outset. In our opinion, it is preferable to communicate to the patient the unpredictability of treatment outcome, and the fact that the best treatment sometimes achieves inadequate results. You should take care not to alter the agreement unilaterally once treatment has begun; neither should you withhold treatment in this situation for non-payment of fees. To do so would leave you open to charges of abandonment.

As to this particular situation, again, this is something that must be decided in the context of your patient's demeanor and your appetite for a showdown. You could offer to refund her money if she surrenders her dentures; you'd be surprised how often a patient is reluctant to do so. Of course, you could try to determine whether there is something you can do to improve your denture service. Not all recalcitrant patients are mentally ill; sometimes, their complaints may even be legitimate!

Follow-up question:
Can I stop the treatment if the client tells me that there are some complications with the payment since it is not really my problem? I Think that one should not worry what kind of impact it has on the client if you make her (especially menopausal women) to sign the contract. It's just protecting the practice. Since, there are even some morons that at my school got insulted because I wore gloves on them since they don't understand the preventive measures.

I could say that the contract is nothing special, and that everyone has to sign it and that I cannot guarantee her that she will like the dentures since it is never meant to be like the real thing. Moreover, her mental adjustment is not my obligation even though it's on my discretion. I can tell her all that nicely and politely.

But if I am forced to deal with her mental issues, would it be inappropriate to tell her that the fee will go up, due to the unpredictable situations in the treatment? I know many practitioners who do that and the client later on finds out that the new fee is higher than the estimate. Can I charge extra for mental work with the client provided it follows the contract?

If she doesn't like it she will not come again and tell to all those like herself not to come to my practice and I can simply fall back to other aspects of dental care so that it wouldn't have an impact on me. I am just trying to have a healthy and profitable practice and not to commit a suicide. They wouldn't appreciate my work on them anyway nor what I had to go through to become what I am.

A: The style of management is something that a dentist must develop for himself over time. It is true that you will encounter all types of behavior, from the simply wonderful to the downright unpleasant all the way to the psychotic. A dentist is not in the business of treating behavior pathology, but it is just good business to develop a sense of what works for different temperaments. As you have already intuitively found, it is not in your best interest to encourage or attract patients that give you ulcers. However, if you carry it too far, you can develop an attitude where you are hypersensitive to any affront, and this can make your demeanor confrontational, if only in subtle ways.

It really helps to try to take the perspective of the patient. Unless you are a dentist, the subject of dentistry, and especially the subjective experience of receiving dental treatment, holds little fascination and much dread. That will almost guarantee that you, as a dentist, will view dental treatment in a more favorable light than your patients. The aversion that patients have will manifest in ways that hinder dental treatment, and can easily be misinterpreted. The patient that breaks appointments or is always coming late, the patient who slides down in the chair, turns his head, constantly rinses, or fails to pay a fee is not always the stereotypical hysterical menopausal woman you describe, but may be almost anyone. These people are struggling to do something they find supremely unpleasant. You will find that these passive-aggressive types make up a disturbingly large part of your practice, and developing a mental strategy of dealing with them will go a long way towards fostering both your practice and your mental health.

Depending on where you practice, there may be laws that forbid the abandonment of a patient-- that is, the unilateral termination of the doctor-patient relationship-- without providing for continuity of care. You may legally negotiate any change in the course of treatment with your patient, and the change is legal if mutually acceptable. You may not unilaterally discontinue a particular treatment or make material change in the treatment before completion without providing in some way for its continuance.

You will find that the most valuable asset a dentist gains over time is not only his reputation for competence, but more importantly, his reputation for compassion and fairness. You will only need to personally experience someone changing a proposed plan in mid-stream once (a general contractor going over budget comes to mind) to know how unfair it feels to have it happen to you. We would recommend against increasing your fee to compensate for your own unanticipated "pain and suffering".

You do not need to have every penny of earned income delivered to you; it is o.k. to lose a few bucks (A FEW!) on deadbeat patients, if it allows you to relax a bit about collections. Patients will eventually sense that you are not in it just for the money...

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