Managing Transfer Cases
It has been estimated that 10% of American families move each year. That means every orthodontist is going to experience significant numbers of transfers every year, both in and out of the practice. How transfer cases are handled can have far-reaching effects on the perception of our profession by the public. Transfers can also be an important source of practice growth.
Integrating transfer patients into your practice can be a challenging process, for several reasons:
I recommend starting with new records at the initial examination appointment, after taking a patient history and a visual examination. Check the appliances for loose bands or brackets and broken ligatures. Reschedule the patient and request the previous records, including financial data, by letter or telephone. You may wish to forego your usual records fee, since the records are for your convenience and protection.
Next, assess the viability of the original treatment plan and estimate the number of months needed to complete the case. Compare this to the previous orthodontist's estimate; if there is a large discrepancy, you might want to discuss the case. The prior orthodontist might agree to make a partial refund, or you may wish to modify your usual fee, so that the total investment for the patient is not too different from the original fee. (The article by Dr. Vogel in this issue suggests one method for computing a transfer fee.) If necessary, regard the case as a "loss leader" and hope that you have generated some positive public relations. Naturally, patients should expect some increase in investment if they are moving to an area with a higher cost of living. And most transfer cases have an adjustment period that prolongs treatment somewhat, which can result in a higher fee.
If you judge that the original treatment plan has no chance of success, you must be both truthful and kind. An example: "There are many ways to treat a case. In my experience, the plan that will work best for Suzie is to extract certain teeth to provide the space that will eliminate the crowding and protrusion. I'm sure Dr. X's plan would also work, but I must treat Suzie the way that works best for me." Calling the original orthodontist can be quite valuable in such a circumstance; he or she might have some important information that would justify the original treatment plan.
It is amazing how often people will accept your explanation, if you make it without implying criticism of the previous orthodontist. The patient may have loved Dr. X, and if you say anything negative, you might find that you are the one who is diminished in the patient's eyes.
If the case needs extensive appliance changes, do not make a separate charge. Absorb the cost. It would be a poor reflection on the profession if patients had to pay additional appliance fees every time they transferred. The changes can be made with no criticism of the original strap-up if the patient is told, "Some of the braces show signs of wear and tear, so I want to replace them with new ones".
When transferring a case to another orthodontist, there are two major considerations: First, you want the patient to have a good experience that leads to successful completion of the case, and second, you want to protect yourself in the event of a dispute or litigation.
You should hold a family conference at the final appointment to review progress and outline the goals of the remaining treatment. Any estimate of the time required for completion should be broad enough to leave the new orthodontist some flexibility. Make extensive notes, so that you can discuss the case intelligently if the new orthodontist calls. Take intraoral photographs to document the patient's condition at the time of transfer. Fill out the AAO or similar transfer form while the patient is available, so that you can accurately describe the history of treatment.
Provide the family with the names of one to three orthodontists whose training is compatible with yours. A prior phone call to ascertain the prospective orthodontist's willingness to take on a transfer case is an excellent idea. Advise the family to schedule an appointment with the new orthodontist and to determine, based on that interview, whether they will be comfortable there. If so, you can authorize the orthodontist to request the records. If not, the family can visit the next orthodontist on the list.
When a request comes for the diagnostic records, you must decide whether to send originals or duplicates. Many risk-management experts advise retaining the originals. Certainly, if you have any concern about patient satisfaction, this is good advice. X-rays can be duplicated easily, and a photocopy machine can reproduce cephalometric tracings. Intraoral slides can be printed with an inexpensive machine that uses Polaroid film. You can take the standard photographs of the models, and retain the photos if you decide to send the original models.
Finally, you might want to review the financial records to determine if the patient's investment is appropriate for the treatment given to that point. A partial refund, if indicated, can be a constructive gesture to make the transfer easier. You might also tell the patient that the total investment could exceed your original fee, because fees vary around the country and because the transfer might unavoidably prolong treatment.
Proper communication is a key to avoiding misunderstanding when patients transfer in or out of your practice. Another key is to follow the Golden Rule of orthodontics: Treat every transfer case as considerately as you would like your cases to be treated by the next orthodontist.