THE EDITOR'S CORNER
Transfer cases have a life of their own in orthodontics. If they are not orthodontic stepchildren, they are at best viewed by most of us with a resigned tolerance. What you usually hear about transfer cases involves the administration of the transfer itself. However, there are important things to be learned from transfer cases that we usually don't bother to learn about our other cases. The reason is that, at the time of transfer, an evaluation is thrust upon us. Whether we are on the sending or receiving end, it is usually necessary to take a look at the status of the case in order to set a fee.
Frequently, such a study at the time of transfer reveals that more work remains to be done than can reasonably be covered by the remainder of the fee due. The combined fee of the first and second orthodontists will be much greater than the original fee quoted. This may cause the patient to feel that one or the other or both of the orthodontists are incompetent or dishonest. What it really means is that many orthodontic treatment time estimates are entirely too optimistic, many orthodontic fee estimates are inadequate for the work required, and many orthodontic fees are collected at a faster rate than the service is supplied.
Collecting fees in advance of service has financial advantages. There is nothing wrong with it, provided that you are prepared on occasion to make financial restitution to a patient who transfers or leaves your practice for any other reason. The more disturbing aspect of the transfer picture is the one in which the patient is called upon to pay one and a half to two times the amount of the original fee estimate in legitimate charges for the combined services of the two orthodontists.
The pressure is on Orthodontist #2 because he is creating the imbalance. The fault lies with Orthodontist #1. Barring extraordinary circumstances, Orthodontist #1 has either grossly underestimated his treatment time or he has a very unsatisfactory method of determining his fees. As a practical matter, these problems are of necessity resolved either with the patient paying a total amount larger than he feels he should or with Orthodontist #2 making an uncalled-for charitable fee for the completion of the case.
Basis for Fees
All orthodontists should have some reasonable basis for determining fees. The ingredients of orthodontic services are well-known. If we are reticent about publicizing dollar values for such ingredients, we may privately recognize that they are the building blocks of our fees which permit us to distinguish between various treatments with some reason. You could spend an instructive hour reviewing at random several cases that you have completed. Put down your treatment plan, time estimate, and fee. Now record what your actual experience was--what went into treating the case in terms of procedures, time, and appliances. See if you can assign dollar amounts to the ingredients of treatment. Try a few cases and see if you see a pattern. Also, see if your time estimates were sound and if your fee estimates generally cover the actual work performed. You may accomplish more than just equitable transfers.
Figuring Transfer Fees
There should be an added burden on Orthodontist #1 in transfer cases. At the time of transfer, he should not only consider what work he has done, but also what work remains for Orthodontist #2. Translating these two items into dollar values will permit him to be fair with his patient and with Orthodontist #2.
Of course, there are other aspects to transfer cases that do not endear them to the profession. Often, a great many preliminary decisions have been made with which Orthodontist #2 may or may not concur. Also, transfer cases are an invasion of one's privacy. Someone else is going to have a look at and a judgment about your treatment, your diagnostic procedures and records, and your fee structure. This prospect is so traumatic to some orthodontists that they will not communicate with Orthodontist #2.
Actually, we are fortunate that we are in a close-knit specialty with a high level of competence and that we can usually transfer our patients under treatment with little or no technical difficulty. All we need do is handle our diagnostic procedures, our treatment planning, our fee structuring, and our actual treatment procedures as if all our patients were going to be transfer cases. 
