professional come in to the office to do I.V. Sedation or oral
sedation, AND all state requirements for sedation are met. PIE
Class II Coverage is also necessary if a PIE insured provides oral
sedation to his/her patients and is certified by PIE to provide this
coverage and follows a checklist issued by PIE on an annual basis
which reviews the certification requirements.
NEWSLETTER
Can dentists obtain class II coverage on a quarterly basis?
--Yes. The insured dentist must submit a fee of $50.00 for
the applicable quarter and submit a note on their letterhead stating
that they need Class II coverage for the appropriate quarter within
which the planned sedation case falls.
VOLUME 28, NO. 2
April-May 2013
Over 30 years of serving the profession
445 East 4500 South #130
Salt Lake City, UT 84107
801-262-0200 Local
800-432-5743 Statewide
801-262-0285 Fax
pie@pieutah.org
www.pieutah.org
Does oral sedation limit a dentist's risk as compared to IV
sedation or even general anesthesia?
--No. Dentists providing sedation in their office must be
able to manage any potential complications that may arise as a
result of their care. Oral sedation does not inherently carry less risk
or more risk than I.V. sedation or general anesthesia. The depth of
sedation, the patient medical history, the provider's training, the
monitoring and equipment utilized are the most relevant factors.
Incidentally there are situations where a deeper anesthetic may
actually carry less risk than a lighter anesthetic, such as can be the
case with asthmatics, for example.
IN MEMORIAM: COLLEEN MANTYLA
1927-2013
Those of you who obtained insurance through PIE from 1984 to
1992 will surely remember Colleen Mantyla, who worked side by
side with Dr. Donald G. Mantyla from 1984 to 1992 when she
retired to serve a mission for her church. You surely appreciated
her wit and humor as well as her ability to put you at ease whenever
you called the office. Colleen suffered the debilitating effects of
Alzheimer’s Disease the last few years of her life and passed away
on March 3, 2013. She is survived by her husband, two children,
fourteen grandchildren and fourteen great-grandchildren along
with hundreds of grateful PIE insured whom she helped over the
years.
Additionally, there is no mention of “oral conscious sedation” in
Rule R156-69 (the Dentist and Dental Hygienist Practice Act Rule)
or any of the ADA documents referenced therein. The Utah
Practice Act does, however, regulate the depth of sedation
provided, regardless of the route. PIE, on the other hand, has
regulations regarding route of administration, as outlined below.
What does PIE require for nitrous oxide vs oral sedation vs IV
sedation in their practice?
--Nitrous Oxide: Class I PIE coverage plus a Class II
State anesthesia permit.
Oral Sedation: Class II PIE coverage, certification by
PIE, Class II, III, or IV State anesthesia permit, as appropriate to
the depth of sedation administered.
IV Sedation (dentist administered): PIE Class II coverage
plus a Class II, III or IV State Anesthesia permit, as appropriate to
the depth of sedation administered.
Oral, Inhalational, I.V. Sedation (third-party
administered): PIE Class II coverage plus a variety of conditions
including provider training, extent of monitoring, etc., as outlined
by the state. applicable to the provider, must be met.
IS SEDATION AVAILABLE?
In my practice of providing sedation and anesthesia for dentistry I
find that many Utah dentists, including PIE insured, have a
misconception that significant effort and expense would be
required to provide sedation in the office. In response to this I have,
in consultation with Dr. Burton and Dr. Engar, created a readyreference list of requirements for your convenience:
For your interest, the May 2013 edition of Anesthesia & Analgesia
focuses primarily on nitrous oxide. Check out anesthesiaanalgesia.org to see the journal cover and for a link to a "video
summary" of the journal which gives some very interesting history,
trivia, and pharmacology surrounding our favorite inhaled
anesthetic.
What is required of a PIE insured dentist for sedation to be
provided by a third party?
--Class II PIE Coverage must be maintained. To obtain
PIE Class II coverage, such the dentist must pay an additional $200
per year and must note that sedation is being provided by a third
party on the Renewal Form. As noted below, this coverage may
also be obtained on a quarterly basis as needed.
Kevin Croft, DDS grew up in Salt Lake City, attended Highland High School an
graduated Magna Cum Laude from the University of Utah. He attended dental
school at Stony Brook School of Dental Medicine and went on to complete a 22
month, CODA accredited, hospital based residency in Dental Anesthesia. He has a
mobile dental anesthesia practice and travels around the state providing all levels
of sedation/anesthesia for dentists in their offices.
What benefit is Class II Coverage to a PIE insured dentist?
--PIE Class I Coverage extends to the use of nitrous
oxide and any oral sedation with valium, vistaril or chloral hydrate.
PIE Class II Coverage extends to I.V. sedation performed by the
insured dentist as long as the insured is (1) certified by the state of
Utah and carries the appropriate state license, OR has another
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IS ANYBODY HOME??
Another issue that arises when patients call with an emergency or
question about treatment has to do with whom they can talk to in
order to obtain proper information. Is a non-dentist receptionist,
assistant, or non-dentist owner of a practice qualified to render a
diagnostic opinion or advice in these situations? The non-dentist
may triage the call and make a determination as to whether the solo
practice dentist or on/call dentist in a group practice needs to be
brought into the conversation. In any case, no diagnosis should be
made by any non-dentist, and no advice should be given by a nondentist other than to tell the patient that they need to speak with the
dentist. Comments like “You should feel better tomorrow morning,
call back then.” or “It sounds like normal numbness, call back next
week if it does not go away” given by the receptionist or any nondentist could land you, the PIE insured, into a boatload of trouble!
Establish protocols where patients with problems can be called
back as soon as the dentist has a break, or the patient is encouraged
to come to the office immediately so the problem can be assessed
properly.
Occasionally we return a call to a dental office or need to follow up
with an issue pertaining to an individual policy only to hear the ring
tone with no one picking up. There is no mechanism to leave a
message. What if we were a patient with an emergency trying to
get in touch with you but nobody is home, or nobody bothers to
answer the telephone. What recourse or alternative would we have
as a patient, or now an angry former patient who must call another
dentist?
You should have a mechanism in place for telephone calls to be
answered and guidance given to patients during times when
personnel are not in the office. Most telephone companies provide
options for voice mail or other methods for patients to hear an
announcement or leave messages. Alternatively you can use an
answering service which can contact you or the dentist on call in a
group practice if a patient has a problem requiring immediate
attention or an answering machine which works as long as it is
checked periodically by someone to check for any patient
problems.
Patients are becoming more astute about understanding how rules
work regarding who is qualified to give a diagnosis or handle
problems and will not appreciate being shielded from the dentist or
given a diagnosis or recommendation by someone clearly no
qualified to render such an opinion.
--RCE
Should you leave your cell phone number on the message to
facilitate patients contacting you? The problem with this method
is that it does not weed out drug seekers or persons who are not
patients of record. A better method, whether you are in solo or
group practice, is for the office to give all new patients a contact
number in the event that they ever have an emergency that requires
immediate attention. In this case you can leave a message to this
effect on your answering device: “If this is a dental emergency and
you are a patient of record, please call the number that you have
been given by the practice to enable you to contact a dentist who
can help you.”
BUSINESS INCOME COVERAGE IN
PROPERY INSURANCE POLICIES
There is often confusion about the Business Income coverage as
part of a Business Owners Policy (BOP). Business Income
Coverage is a complicated coverage and requires documentation on
the insured dentist’s part to prove their loss. When a business
suffers a covered property loss, such as fire, theft or vandalism, it
may be forced to close for some time. Loss of Income coverage as
part of most insurance companies with which Berkley Risk
Services place Business Owners policies, is settled on an Actual
Loss Sustained basis. Business Income is defined as:
Net income (net profit or Loss before Income Taxes) that
would have been earned or incurred; and
Continuing normal operating expenses incurred.
Usually this coverage is paid for up to 12 consecutive months after
the date of direct physical loss or damage. As a standard adjusting
practice, the insurance companies typically don’t consider that a
dental office has suffered a short term loss, as patients can be
rescheduled.
This practice results in many unhappy dentist
claimants.
Some of the companies make available a daily
indemnification limit, for 10 to 15 business days, for these short
term losses, after which Actual Loss Sustained will apply. Daily
limits vary, and can be purchased up to $5,000 per day, depending
on the insurance company. All losses must be proven with proper
documentation, including the daily indemnification limit. Usually
this is an unpleasant and time consuming process for the insured
dentist.
Are you obligated to be available 24/7 for anyone with an
emergency, regardless of whether or not they are a patient of
record? The ADA Code of Ethics states the following:
4.B. Dentists shall be obliged to make reasonable arrangements
for the emergency care of their patients of record. Dentists shall be
obliged when consulted in an emergency by patients not of record
to make reasonable arrangements for emergency care.
How should this be interpreted? Naturally a dentist in solo practice
can be considered to be on call 24/7 to deal with problems with
patients of record. If the solo practitioner leaves town or is on a
cruise or in a remote area where consultation by cell phone is
impossible, he/she should make arrangements to have a colleague
take call or handle any emergencies and the colleague’s name or a
staff member’s name can be left on the announcement to guide a
patient into finding help. In a group practice, the dentist on call has
the obligation to be available to help any patients of record deal
with an emergent problem.
If a patient calls who is not a patient of record in either case, if the
solo practitioner or dentist on call is unable to help, a reasonable
arrangement would be to advise them to call one of the emergency
dental services that advertises in the telephone book or online, etc.
to obtain help. Another alternative is to make arrangements with a
new graduate or dentist who is trying to build up a new practice
who could use new patients to see the person calling with the
emergency.
It is important that you check your policy to see what it covers, as
policies vary, and to avoid surprises at the time of a loss. Call
Heather Cantrall at Berkley Risk 877-502-0106 should you have
questions or need additional information.
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responsibility when they know that these services are
necessary.
Did you know that Berkley Risk Services also provides Workers
Compensation Insurance at very competitive rates? It is mandatory
for you to carry workers compensation insurance for the protection
of your employees. It may be worth your while to mention that you
want a quote from Heather to compare what Berkley can offer to
what you are currently paying.
The truth is that such forms are not worth the paper they
are printed on and will not hold up in court because you
as the dentist cannot be excused for negligence on your
part. As far as x-rays go, ADA Guidelines are clear on the
fact that not all patients in your practice need bitewings or
other x-rays every six months. Indeed, many patients have
such good hygiene and such a low decay rate that they
probably don’t need x-rays any more often than a two year
interval. Other patients with poor home care, dry mouth
conditions, etc. may be hard to maintain even with x-rays
every six months. You must determine the proper
frequency for every patient. If for some reason (probably
related to their insurance not paying for them at the
frequency you recommend) a patient of record refuses
your recommendation for x-rays, you should use the
following dialogue:
“We have a culture of prevention in this practice
and strive to do the best we can to maintain good
dental health in all of our patients. If you don’t
allow us to take x-rays we really can’t do our job.
As you have been a good patient in the past we
can let it go this time only, but next time we will
need to take x-rays. You should check with your
benefits department at work and complain that
they are cutting back on preventive benefits that
you would like them to maintain as is."
Then, you should make a note in the patient’s chart that
you discussed the need for x-rays and the patient refused
but agreed to allow you to take them next time.
This information is provided to advise of general policy terms only and does not
amend or replace the actual policy provisions. Please consult your policy terms,
conditions, exclusions and definitions for how coverage applies. We appreciate
Tandra Casserly of Berkley Risk Services for providing the information contained
in this article.
SOME SHORT SUBJECTS:
1.
2.
WHEN NOT TO CALL PIE: We are experts at
malpractice matters and are more than happy to help you
deal with any problems or potential claims that are caused
by unhappy patients or incidents in your office that may
trigger problems in this arena. However, we are not
experts in the areas of employment matters, injuries to
employees or private dental insurance plans that patients
carry. If you encounter problems in these areas instruct
your receptionist, office manager, etc. not to call PIE but
instead to call the following:
a. Employment problems: Call Workforce Services at
801-530-6801.
b. Employee injuries such as needle sticks: Call your own
workers compensation insurance company for advice.
c. Private dental insurance problems. The ADA has an
entire department devoted to helping you with various
situations in this arena. Their ADA number is on the back
of your membership card and you must have your ADA
number handy when you call. Alternatively, you can call
the Utah Insurance Department to voice a complaint or
concern and they can be called at 801-538-3800.
For a new patient, you should be more adamant, and the
dialogue should be as follows:
“We have a culture of prevention in this practice
and strive to do the best we can to maintain good
dental health in all of our patients. If you don’t
allow us to take x-rays we really can’t do our job.
As a new patient, we cannot properly diagnose or
even treat you. If you wish to become a part of
this practice, you need to let us do things as we
recommend that they should be done. If not, we
can stop right here and you can find another
dentist who is less prevention minded.”
PATIENTS ARE AWARE OF DIRTY OFFICES
Thanks to an allegedly sloppy oral surgeon in Oklahoma,
some of your patients may be asking you about the
techniques you use to ensure sterilization of your
instruments, etc. Be prepared to show your patients the
steps you take to ensure that the instruments you use are
clean and sterile. Show them the sterilization tape you
use, for example, and show them your autoclave if they
want to see it. Explain that there has never been a case in
a Utah dental office where it was confirmed that HIV or
AIDS was diagnosed in a patient as a result of the virus
being transmitted in a dental office for any reason.
Explain that you pride yourself in the cleanliness of your
instruments and would have no hesitation in using any of
them on your mother or children, etc.
The conversation should be documented in the patient’s
chart, even though the entry will be short, etc. since the
patient will be sent away from the practice.
If the patient insists, even after hearing this explanation,
on no x-rays, you really have no choice but to show them
the door as they will continue to fight you on other
recommendations and will be the type of patient to
threaten a claim the minute something goes wrong. Also,
these patients end up seeing another dentist on an
emergency basis, generally for a previously undiagnosed
periodontal or endodontic abscess and when the
emergency dentist is allowed to take several x-rays and
then asks them if they have a regular dentist they will say,
“Oh, yes, I go to Dr. Jones every six months!” The new
3. ARE THERE ANY DISCLAIMERS OR FORMS
FOR PATIENTS WHO REFUSE X-RAYS OR
PERIODONTAL TREATMENT WE RECOMMEND?
It seems that almost on a weekly basis we get a telephone
call from a PIE insured asking us if we have a disclaimer
that a patient can sign who refuses x-rays or periodontal
treatment and wonder how they can be absolved of any
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dentist will say, well, then Dr. Jones missed some things
for your mouth is a mess and you have several problems I
can see on these x-rays I took!” The patient will not tell
them that they have refused x-rays every time they have
seen you but will still blame you for their problems and
expect you (or PIE) to pay for their implants and
reconstruction.
be potentiated by the patient being extra careful not to
disturb the clot and by avoiding chewing on the involved
side during the healing process.
--RCE
LIFE POLICY RESCUE
If you recommend periodontal treatment even as simple
as root planning and scaling and the patient refuses, or
they are so far advanced that you need to refer them to a
periodontist, and they refuse but insist that they will sign
a disclaimer, etc., you will need to use a similar dialogue
to what we have described previously, except you cannot
give them a pass or bye but must explain that there is no
point in your doing fillings or crowns or other such work
if they refuse to let you maintain the foundation that holds
their teeth in place.
Over the past thirty years, two of the most popular types of life
insurance contracts purchased in the marketplace have been
universal and variable universal life policies. These have been
popular because of their flexibility and because of their relatively
low minimum premiums as compared to traditional whole life
contracts. My purpose in this article is to alert you to the very real
possibility that these two types of life insurance policies may have
built-in self-destruct features that may cause the policy to expire
before the need for the protection does.
In order for a variable universal life policy to perform as intended,
at least four basic requirements must have been or continue to need
to be met. The owner needs to be sophisticated enough to
understand the risks inherent in these policies; the owner needs to
be committed to ongoing policy management; the policy must have
adequate funding in order to overcome the loads built in; and the
agent must be willing and able to provide ongoing service to the
policy owner. These requirements also apply to regular universal
life contracts, although to a somewhat lesser extent because of the
lower risks inherent in these vehicles. The two environmental
factors that have threatened these contracts come directly from the
economy since the early 2000’s: Prolonged historically low
interest rates and the erosion of equity values during the real estate
crash and the resulting stock market implosion. More recent stock
market gains have helped, but may not have entirely healed the
wounds in these policies.
The first step in managing one of these contracts is to request an
“inforce illustration” from the company that issued the contract.
This will provide a projection of how the policy will likely perform
going forward, assuming that all current costs and earnings
continue. From this inforce illustration, it can be determined if
there is enough current value and ongoing premiums in the contract
to enable it to perform going forward. Once this document is
reviewed, a determination can be made as to whether the contract
needs intervention in order to survive. Intervention may take the
form of a reduction in the death benefit, immediate cash infusion,
an increase in premiums being paid in, a combination of the above,
or complete replacement before both the current cash value and the
death benefit disappear. This analysis can be done by any
competent life insurance agent (assuming he/she is also securities
registered), and by some CPAs.
One word of caution: Most people really don’t know much about
the life insurance policies they own when they make the purchase,
let alone a year, or two, or ten years later. If you haven’t reviewed
your coverage in more than a year, make the time for an in-depth
review sooner, rather than later. You might have one of these
endangered contracts and not know it. Please note also that many
of these policies were purchased to fund buy/sell agreements and
estate plans. The impact of the implosion of the coverage provided
by these contracts may be magnified in these cases by the role the
policy may play in making these legal arrangements work together.
4. WHO IS QUALIFIED TO PLACE SEALANTS?
The Utah Practice Act allows hygienists or dental
assistants to place sealants but there are limitations and
issues that must be considered as follows:
A. Nothing with the potential of removing substantial
tooth structure, such as an air abrasion unit, can be used
by an assistant or hygienist. Acid etch is the only medium.
B. The tooth must be isolated, either by application of a
rubber dam or the use of some other mechanism to keep
the tooth or teeth dry during the process.
C. Care must be exercised not to leave so much material
on that the occlusion must be adjusted. Neither the
hygienist nor the assistant is allowed to use any type of
handpiece to adjust the occlusion. That duty falls to the
dentist.
D. No matter how large the sealant, you can never upcode
or try to bill insurance for a filling, especially if it is placed
by a hygienist or assistant. A sealant is a sealant!
5.
I NEED TO DO AN EXTRACTION FOR A
PATIENT ON COUMADIN. DO I NEED TO USE ANY
SPECIAL PAPERWORK?
The standard of care for dentists is not to recommend that
a patient discontinue the use of Coumadin but to have the
patient undergo an INR prior to the procedure and use
local factors to control the bleeding if an extraction is
planned. If the INR is <3.0 and the extraction is expected
to be routine, then you can proceed. If multiple
extractions are planned and you have never used some of
the clotting factor materials that can be used to help stop
bleeding, and you lack experience in dealing with these
situations, than it would be wise to simply refer the patient
to an oral surgeon. As far as informed consent, it would
be wise to highlight the portion of the oral surgery
informed consent form that describes bleeding and note
that the risk of complications in this area is heightened by
the patient being on Coumadin. Furthermore, the patient
should be counseled to refrain from any rambunctious
behavior, refrain from bending over to pick up a pet, etc.,
no smoking and no picking at the clot. Good healing will
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Terry W. Rushton, MBA, CPA, 6995 Union Park Center #190, Cottonwood
Heights, UT 84047. Ph: 801-676-1500; Fx: 801-676-1505. In addition to the CPA
license, Terry also holds a life insurance license and FINRA Series 7, 65, & 24
securities registrations.
GUEST COMMENTARY
A BANG-UP DENTAL TALE FOR YOU!
Sometimes we are criticized for having too many “heavy” articles
in this newsletter. Dr. Clifford Daines of South Ogden sent me a
brief report some time ago that I thought might generate a good
laugh or two as you get to the end of this Newsletter. Thanks to Dr.
Daines for taking the time to submit the adventure. And, no, this
was not something he recommends you try at home!
Dr. Engar and I have started the lecture series again across Utah in
Spring 2013 with the intent to help us, as dentists, to understand
some of the ways we can improve our practices and, along the way,
point out some of the things we can do to keep dentistry safer and
keep you, our insured, away from lawsuits. We were asked by the
new dentists who have not heard the program and by those who
were unable to be present for the past lectures, to give them the
opportunity to hear the presentation. We have found the dentists to
be most gracious and receptive to the message, and are encouraged
to find that they are incorporating the ideas into their practices.
Sometime shortly after the turn of the century in southeastern Utah,
an older gentleman had some serious decay in one of his back teeth
that was described as “being about the size of the end of your little
finger. It was beginning to bother him and he needed to do
something about it. But he lived too far away from any dentists,
and the time and cost of the trip would have been too prohibitive to
go have a dentist take care of the offending tooth.
The last series of lectures were given two years ago, and we have
studied the results. We have found only one new case, dealing with
the subjects discussed in the course, to have resulted in a claim file
being opened since that time. We are very heartened with the way
the dentists (you, our insured) have been able to protect themselves
with the information.
The older gentleman had been a miner, and had done mining for a
lot of years. So he decided to take matters into his own hands. He
carefully rolled a small amount of dynamite into a cone and shoved
it into the furcation area of his tooth, lit the fuse, and waited for it
to explode. After the planned explosion he reached in and pulled
the pieces of tooth from his mouth. The tooth was gone!
It is interesting to note that as the dentists have started using
informed consent forms in most of their procedures, they have
driven down the cost of litigation. It is most imperative that the
dentists protect themselves by using this most important document.
If you are not familiar with our library of available forms and nee
one for a particular procedure, or think that we should have a new
one custom made for a particular procedure, call PIE and we can email specific forms or the entire set we have available. We have
found that the lack of an informed consent to be the number one
reason we will lose a case and/or have to pay a settlement.
Whereas, five minutes of your time spent going over the risks in
the informed consent and having the patient review form and sign
it will save hundreds of hours in litigation. Also, as an aside, make
sure the patient not only reviews the form but signs the form before
you begin the actual procedure.
His granddaughter, the person who provided the account to Dr.
Daines, was talking to her grandma late in her life. She told
grandma that she did not want to be promoting a fictitious story and
not have the facts right, and asked if she could repeat the story back
to her for verification. Upon completion, grandma became rather
annoyed and said “It’s not like he didn’t know what he was doing.
After all, he was really good at mining and knew exactly how big
of a charge to put in there!!!”
SOME 2012 NUMBERS FOR YOU
Generally in the April Newsletter we try to publish statistics from
last year as far as new dentists coming in vs. dentists retiring or
leaving the state. As we have been unusually busy this Winter and
Spring with various projects such as the regularly scheduled audit
we undergo every four or five years with the Utah Insurance
Department I have not been able to compile all the statistics at the
time of publication of this Newsletter. We will have the complete
set ready for you to review in the July edition, however, so stay
tuned. To whet your appetite, however, I am happy to provide some
preliminary figures here:
We will finish the second phase of our lecture in June and hope to
see all of those who have not taken the opportunity to take part in
this most important, informative event. We filled the room to
capacity at the first lecture in the series at Maddox Restaurant in
northern Utah and hope to see a similar trend in the remaining three
locations.
During 2012 we observed the following:
1. 32 dentists retired. 10 of these stopped practicing to
serve church missions. The average age of those strictly retiring
was 71.
2. 20 dentists moved or established satellite offices
3. Five dentists died of various maladies, including cancer
and heart attacks. Ages ranged from 37 to 85.
--RCE
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