It’s the Point of Transaction

Tom M. Limoli Jr


Having lived in the dental benefit family and having been associated with the dentistry for the better part of the last 40 years has been an eye-opening experience for me.

As a preteenager working in my father’s dental laboratory, I learned the importance of early stage preparation and execution. It’s the minor, often overlooked, details that will fail a case. Skip the proper preparation of the impression, mix the stone inconsistently, pour the model incorrectly, misread a margin, and the die is wrong. When the die is wrong, the wax-up, investment, and casting will also be incorrect. At this point, the ceramist has (unknowingly) already failed. When the little things gets overlooked or misinterpreted, it has a tendency to cause big problems down the line. Such is the case with today’s changing demographics, concerning the delivery and subsequent administration of dental care.

Yesterday’s models of healthcare delivery are not applying to the wants and needs of today’s patient base. And now more than ever, savings, convenience, and immediate gratification at the point of transaction motivate our patients.

But, what about the point of transaction?

Let’s break down the transaction into its various evolutionary phases so as to better grasp the root of this growing issue.

The traditional single-doctor dental practice re­­mains, to this day, the standard by which dentistry is seen and measured. Take 1.2 dentists add 1.6 hygienists, a clinical assistant or 2, along with a pair of administrators, and you have a typical 4.6-chair dental office. Is this demographic delivery model an endangered species? Many in the profession say it is. But wait.…

Now let’s take a second set of traditional single-doctor dem­ographics and add it to the existing 4.6-chair facility. Essentially, we now have 2 complete office teams under one roof and operating as one entity. This small group, working simultaneously, has the a­bility to see and treat more patients at varied times of the day. This model better serves a larger segment of the population than the traditional single-doctor practice can working alone.

Tweak your employer numbers, and employee numbers, along with values and we now have a small group practice ready to be part of a larger organization. This is referred to as either a dental service organization (DSO) or management service organization (MSO). Compare and contrast the 2 on your own if you so desire, but in a nutshell, the difference is basically in who actually owns what.

Is this the organizational model destined to take over the dental profession? Some say it is inevitable. Many have thrown their hands up in surrender while others have thrown theirs up in anticipated hopes of selection. Is the private practice of dentistry soon destined to the same evaporating extinction suffered by Drs. Marcus Welby and Steven Kiley? Is the return to the point of transaction that which all of dentistry is seeking?

As yesterday’s naysayers speak gloom and doom with the passing of dentistry’s golden years, the entrepreneurial spirit burns bright in the next wave of organizational development. Dentistry, and its most honored profession, have yet to realize its greatest potential. This upcoming wave recognizes—and is building its foundation upon the rebirth of—the missing component. Despite traveling through a void, and being led astray, the maturation of the dental profession continues. Basically, the profession and association went one way, while its clients, customers, and patients were continuing elsewhere to their own destination.

The future of dentistry is no longer based upon the fee for a crown. For too long, dentists placed hollow value in their offices upon the number of crowns delivered each week, month, and year. Add a few more dollars to the mix and simply raise all your fees 3% a year, and your patients will follow you until the end of time. That was the hope and dream of yesterday that led dentistry astray. The concept that fee-for-service reimbursement was the only representation of quality was one of the final nails in its coffin.

You see, fee-for-service is not, and never was, a measure of quality. Quality is represented solely with and by the hands, eyes, and soul of both the doctor and the patient being served. Fee for service is merely payment received based upon completed procedures. Put the widget in the box. Put the box on the truck. For each box you put on the truck, you get you a single dollar. The more boxes you put on the truck, the more dollars you get. That is fee-for-service; the more you do, the more you get.

The failure of today’s corporate DSO and MSO concept is that they are still entrenched in yesterday’s failed fee-for-service concept. All too often, the treating dentist is “forced by fee” to overdiagnose, as well as overtreat, based upon the wants and needs of quota-driven management; this, rather than delivering quality and appropriate patient care. Management cannot determine appropriateness in the absence of peer-reviewed professional diagnosis. That is but one of the failures of today’s corporate delivery concept. With time, supply and demand will continue to change the scope and culture of this delivery system, thus bringing them back to their point of transaction.

Not far behind are some of the multidoctor group practice models. Be they general or multispecialty, they too place much relevance on the fee-for-service concept. They see that if the full UCR for a molar root canal is $1,300, but the plan maximum allowable charge is only $900, they have taken a $400 loss. If the office does 3 of those procedures in a day, they believe that they lost the entire fee for one more completed root canal. Was money lost doing the procedure at a reduction to the full fee? The only way they lost money was if the chair remained empty. The root canal was done for $900 because you did not have a patient ready willing and able to have the procedure completed for the full fee of $1,300.

Now with the 2 previous examples, consider this: Are you doing that $900 endo with recycled reamers and files because you are not getting your full fee? If the procedure fees were for a crown rather than endo, would you use a cheaper dental laboratory or perhaps send the case to an offshore lab? Please don’t think for a minute that this would be a reasonable solution. If selected treatments are in any way based upon reimbursement, everyone loses! Control is achieved in the appointment book, not the operatory.

The single-doctor concept still holds the magical key to tomorrow’s continued en­tre­preneurial success. It is here where the basic fundamental building blocks that encompass the point of transaction were born, nurtured, matured, and will continue to evolutionarily guide the profession. The rebirth of the new expanded single-doctor concept is rapidly approaching as a potential and viable dental delivery mechanism.

This administrative framework is not based on the individualistic fee-for-service concept, but does live and grow with its corporate DSO and MSO cousin. The main difference is that the dentist is paid to be a dentist rather than a piecemeal sharecropper paid a dollar for every box that was put on the truck. Think about how you pay your administrative team. Do you give them a dollar each time they answer the phone? Do they get another dollar when they schedule an appointment or collect patient copay? Now, how about your clinical team? Is an explorer worth more than a mirror?

When doctors are paid to be doctors, appropriateness of care returns to center stage. Thus, the point of transaction becomes realized. What point of transaction? I’m talking the doctor-patient relationship. Throw a pebble in a pond and the ripples radiate from the center point of impact. In the dental office, that point of impact is the core of the doctor-patient relationship, where everything we do is a result of the patient in the chair.

The winner is not yet up to full steam on the playing field. And the winner is not corporate. It’s institutional.

An expert on proper coding and administration of dental insurance benefit claims, Mr. Limoli is president of Limoli and As­­­sociates/Atlanta Dental Consultants. He received a BS in criminal justice from Valdosta State University. Following his work with the US Treasury Department’s Federal Law Enforcement Training Center, he has actively investigated fraudulent claims for the insurance industry as well as numerous other third-party fiduciaries. He is a licensed private investigator and a member of the American Association of Dental Consultants, the National Speakers’ Association, and the National Health Care Anti-Fraud Association. He is the past president of the Academy of Dental Management Consultants. He is the author of Dental Insurance and Reimbursement Coding and Claim Submission and co-author of Fee-for-Service Dentistry With a Managed-Care Component. He can be reached via

Disclosure: Mr. Limoli reports no disclosures.