How to Optimize Dental Production When Your Hygiene Schedule Is at Capacity
Updated: Aug 12
There may come a time when you have two full-time hygienists and never intend to add a third. Or you may have three full-time hygienists and never intend to add a fourth. You may practice alone or already have a partner or associate. Whatever the case, if your hygiene schedule is at capacity and you do not want another dentist or hygienist, what should you do?
Having more patients than you have the capacity or desire to accommodate is a luxury most dentists cannot afford. If you have reached that point, you have options that can dramatically increase production, collections, and the pleasure of practicing dentistry—without expanding the practice.
A Luxury Problem: More Patients Than You Can Accommodate
I worked with a practice led by two dentists with four full-time hygienists. Hygiene was booked more than six months in advance, and the office was having trouble scheduling six-month recalls for current patients. At the same time, the practice was attracting more than 60 new patients per month.
That is a luxury problem, but it is still a problem. With no additional capacity, making room for more than 60 new patients meant allowing more than 60 existing patients to fall through the cracks each month. The dentists did not want to add another dentist or hygienist. They had reached the size of practice they wanted.
If this is your situation, you have two primary options: cull the patient base, cull the insurance plans that consume too much of your limited capacity, or do both. Done correctly, both can improve production, collections, office culture, and your enjoyment of dentistry.
Strategy 1: Cull Your Patient Base
First, you can cull your patient base. This sounds awful, I know, but hear me out. When you have more patients than you can accommodate, some will inevitably fall off the schedule. They may decide they cannot wait for your next available appointment and go to another dentist. That may be acceptable for some patients—but do you really want to lose the patients who always show up on time, pay their bills, share your philosophy of dental care, and arrive with a great attitude? Instead, focus on keeping those patients.
Since some patients will be lost, make sure they are the patients with chronic past-due balances, the chronic cancellers, the rude or difficult patients, and the patients who never accept treatment. There. I said it. You can be more discriminating about your patient base.
Office culture matters. Production and collections matter. No-shows matter. If you have earned the luxury of being selective, use it to create a more profitable practice that is also more enjoyable for you and your team.
Stop Chasing Chronic Cancellers and No-Shows
Eliminating chronic cancellers frees schedule time and condenses the schedule around reliable patients. That boosts profitability because broken appointments are extraordinarily expensive in dental practices.
This does not have to happen all at once. It can be a gradual process. Whenever a patient cancels or fails to show, review the history and consider marking the account “Do Not Call.” If a chronic canceller later calls to schedule, require a significant, nonrefundable deposit—or tell the patient you will no longer reserve appointment time for them.
Prepare for that conversation before the patient calls. Say directly: “You have missed or canceled several appointments that we reserved for you. Our hygiene schedule is full, so we can no longer reserve another appointment without a nonrefundable deposit.” Then stand by the decision.
Stop Scheduling Patients With Chronic Past-Due Balances
Patients with chronic past-due balances should not continue occupying scarce appointment time while the office hopes they will eventually pay. Put the account on hold until the balance is paid.
Prepare what you will say: “Before we can schedule another hygiene appointment, the past-due balance on your account must be paid.” Then stand by the policy.
Eliminate the Patients You Dread Seeing
Some patients drain all the good energy from the room. You know the type. Consider eliminating that energy vampire from the practice. A dentist does not have to continue treating someone who is rude, difficult, or unpleasant.
Keeping the cream of your patient base and removing the difficult patients can improve the quality, fun, and profitability of the practice. It also strengthens the office culture you have worked to create.
This may require a tense conversation. Prepare for it so you are not caught off guard. Decide who will speak, what will be said, and whether the patient will receive a formal dismissal letter. Keep the conversation brief. You do not need to debate the patient's behavior or persuade the patient to agree with your decision. Politely stand by the decision.
Consider Fundamental Differences in Treatment Philosophy
If a patient never follows through with treatment or always chooses the cheapest fix regardless of long-term viability, consider whether there is a fundamental difference in treatment philosophy. A patient who never accepts recommended dentistry is clogging up your hygiene schedule while other patients wait for an appointment.
You are not required to keep every patient forever. When the relationship no longer fits the type of dentistry you want to provide, decide whether that patient still belongs in the practice.
Use Quiet Attrition — or Dismiss the Patient Directly
You do not have to send every patient a dismissal letter. Put less desirable patients on a “Do Not Call” list and stop pursuing them when they fail to schedule or miss an appointment. Quiet attrition will take care of some of these relationships.
If that does not work, be prepared to have the difficult conversation. Some patients will need to be formally dismissed from the practice.
This idea may scare you, but in my experience the fear is unfounded. I have never had a client regret dismissing a difficult patient. The dismissed patient may complain, but that does not mean the complaint will damage your reputation. Your reputation is built on the care you provide, not on your willingness to tolerate unacceptable behavior.
Strategy 2: Cull Your Worst PPO Plans
A second tactic is to drop the insurance plans with the most egregious write-offs. Across the board, reimbursements have not increased fast enough to keep up with inflation, so PPO write-offs continue to climb. Some now exceed 50% of my clients' usual fees.
Dentists care about their patients and want to provide excellent dental care. They are also in business to make a living. Insurance companies can push reimbursements down only so far before it becomes untenable for the dentist. When hygiene is already full, there is no reason to fill scarce appointment time with patients covered by plans whose reimbursements barely cover overhead.
Measure the Write-Off and the Number of Patients
Before dropping a plan, determine the true write-off from your usual fees and the percentage of active patients covered by that plan. A plan may have large write-offs but also cover a significant portion of your patient base, making it riskier to drop.
Also consider your new-patient flow and how far out hygiene is booked. If you have enough patients to keep the schedule full after dropping the plan, it is possible to collect more after dropping it. The following example shows how.
If you are evaluating a broader move away from PPO participation, read our article Fee-for-Service vs. PPO Insurance: Where Should Your Dental Practice Be on the Scale? for a more complete discussion on making that decision.
How Dropping a PPO Plan Improved Collections Without Adding Capacity
In the four-hygienist practice described earlier, an insurance analysis showed that 13.5% of the patients were covered by the PPO plan with the worst reimbursement — a whopping 54% write-off from the practice’s fee schedule. The doctors and I decided to drop that plan, and the practice went out of network.
The practice did not miss a beat. The hygiene schedule went from being booked seven months out to five and a half months out. The practice was still beyond capacity, but they were receiving better reimbursement for the patients it saw. Collections increased with no increase in workload.
We then evaluated another plan that covered 9% of the practice's patients and required a 46% write-off. Dropping it brought the hygiene backlog down to four and a half or five months. The practice is still full, but more of the patients it sees have better reimbursement. Collections increased again without the dentists working more hours.
Use Selective Culling to Build the Practice You Want
You have only a limited number of work hours in which to see patients. Why waste them on PPO plans with huge write-offs and reimbursements that barely cover overhead? See a more select group of patients with better insurance who show up for their appointments—and watch profits increase.
Most of my clients enjoy the clinical side of dentistry but not the business side, particularly insurance reimbursement and patient no-shows. Don’t let untenable reimbursements or inconsiderate patients steal your joy in practicing dentistry. If you have the luxury of a full hygiene schedule and a decent new-patient flow, improve the quality of the practice through the art of selective culling.
Concentrate the practice around people who share your treatment philosophy, are pleasant to you and your team, have good insurance or no insurance, and, most importantly, show up for their appointments. Then enjoy the fruits of your labor.
Do not let fear stop you from having the practice of your dreams. Most fears are unfounded. As the old saying goes, “I have had a lot of worries in my life, most of which never happened.” (Often attributed to Mark Twain)
Be bold. Stand your ground. Stick to your principles. Do not settle.
Ready to Make More of the Capacity You Already Have?
A full hygiene schedule should produce more than a long wait for appointments. With the right patient, scheduling and insurance decisions, the capacity you already have can support better production, stronger collections and a healthier office culture.
If your practice is maxed out and you do not want to expand, we can help you identify where limited capacity is being lost—and how to use it more profitably without sacrificing excellent patient care. Schedule a free, no-obligation practice analysis to discuss what may be possible in your practice.
About the Author
Russ Ledbetter is a dental practice consultant with The Ledbetter Group. Since 1989, for over 35 years he has worked inside dental offices to improve production, strengthen systems, and develop high-performing teams—without raising fees or changing clinical philosophy. Learn more about Russ and our Dental Consulting Services.
