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Dr Chinwe Akuonu explores fluoride misinformation, personalised preventive care and how a patient-friendly approach can improve the compliance with and effectiveness of fluoride treatment.

In this episode of Dentistry Connected, Solventum clinical advisor Karen Toole speaks with general dentist Dr Chinwe Akuonu about the changing role of fluoride therapy. Their conversation explores misinformation around fluoride, the importance of personalised preventive care and how factors such as taste, texture and treatment time can influence patient compliance.

They also discuss Clinpro Clear fluoride treatment and how a clearer, simpler and more patient-friendly application could help bring professional fluoride treatment into the modern dental practice.

Have patients become more prevention-aware, or are they more confused?

Chinwe: I would say both. They are definitely more prevention-aware, thanks to social media. We all have access to the internet on our phones, so if you are ever confused about something, you can look it up.

We know how expensive it can be to treat disease, especially dental disease, and we are aware of the NHS crisis and people who do not have access to dentistry.

At the same time, there is still a lot of confusion. There is a lot of information out there, but sometimes that information can be untrue. Patients come into practice and say, ‘I read about this’ or ‘I saw this video on TikTok. What do you think?’

Fluoride is particularly relevant. Patients ask: ‘Is it toxic? Is it not toxic?’ When we are about to put fluoride varnish on children, parents can sometimes be worried.

When we talk about fluoride, it is about understanding that many things are good for us but can be harmful in very high doses. Fluoride is one of those things where we weigh the benefits against the possible damage. When it is used within the recommended doses, we know that it works really well.

How do sensory sensitivities such as texture, taste and smell affect compliance?

Chinwe: They definitely affect compliance, especially with children. If a child does not like the smell or taste of something, they are not going to let you put it in their mouth. They will spit it out straight away.

After fluoride application, we tell patients not to eat or rinse. Imagine having a taste you do not like in your mouth. As soon as you step out of the practice, you are going to spit it out and rinse.

For a patient at high risk of dental disease, that protection is then gone. If there is no compliance, we are wasting our time, money and resources.

The consistency and texture are also important, particularly for neurodiverse patients. After the application of some fluoride products, patients can experience a sticky feeling. Children sometimes sit with their mouths open because they do not know what to do. They are thinking: ‘Should I stay open? Should I stay closed? Can I swallow?’

These factors can seem like small details, but they can make a significant difference to whether the treatment is accepted and ultimately effective.

Why is toothpaste not enough for some patients?

Chinwe: Because we are not all the same. Some people are more predisposed to developing disease.

Patients may be neurodiverse, have impaired mobility, gum recession, hard-to-reach areas or deep pits and fissures. These factors increase their risk, and the amount of fluoride in a regular toothpaste may not be enough.

That is when extra professional care and the application of a high-fluoride treatment become important.

Sometimes patients try their best to do everything correctly, but every time they come in, there is another cavity. They are brushing, flossing and using interdental brushes, but they still need extra help.

It is not one size fits all. It is about understanding the patient’s risk of dental disease and creating a care plan specifically for them.

How is Clinpro Clear different from traditional fluoride varnishes?

Chinwe: From my point of view as the dental professional applying the product, it is very easy to use. It has a single-use applicator, and it is simple to press, activate and apply.

I have found that it sticks to the tooth rather than the brush. It is also clear and transparent, so the patient does not get up from the chair with a coloured varnish visible on their teeth.

Having that clear, smooth feeling on the teeth is important for patients. There are also different flavour options for different kinds of patients. There is a flavourless option, which can be useful for neurodiverse patients, as well as mint and watermelon.

We are all different in terms of flavour and sensory preferences. Giving patients options can help make the experience easier and improve their acceptance of the treatment.

Listen to the full conversation on YouTube or Spotify.

Click here to find out more about Solventum.

This article is sponsored by Solventum. Solventum, the S logo and Filtek are trademarks of Solventum or its affiliates. 3M is a trademark of 3M company.

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Regardless of your age, you are never too old for orthodontic treatment. Age is rarely a deciding factor for orthodontic treatment. While your orthodontist will consider many variables when developing your customized treatment plan, it can be as successful for adults as it is for adolescents. In fact, one in three orthodontic patients is an adult, proving that you don’t have to let your age keep you from the smile you’ve always wanted.

Adults Can Get Braces, Too

Although adults have greater bone density than children, the same principles for creating a beautiful smile apply to the young at heart. Check out this short clip from an AAO orthodontist and start your smile journey today.

Age and Tooth Movement: Is There an Impact?

Whether you’re 8 or 80, the physiological process that moves teeth through bone remains the same. Teeth move in response to forces being placed on them over time, regardless of how old you are. Many orthodontic problems can be corrected as easily for adults as for children and teens. While you may not be an adolescent anymore, your teeth can still be moved and adjusted to create a beautiful smile and a healthy bite.

How is Adult Treatment Different from Child Orthodontics?

The biggest difference in orthodontics for adults vs. children/teens is that adults are no longer growing. While this won’t impact the success of orthodontics, adult treatment may take slightly longer than that of a child with a similar problem, due to the maturity and density of adult bone tissue.

Additional factors your orthodontist will consider when determining the optimal treatment include the presence of fillings, missing teeth, misshapen or worn teeth, or dental diseases. Some medications and habits, like smoking, clenching or grinding teeth, or tongue thrusting, can affect the outcome of treatment. It’s common for orthodontists to work with a child’s family dentist to coordinate care, and the same applies to adult orthodontics. For some adults to reach optimal dental health, the dentist and orthodontist may need to call in other dental specialists such as oral surgeons, periodontists, and endodontists.

How Does the Adult Treatment Process Work?

To move your teeth to their ideal positions, your orthodontist will use an “appliance” to deliver controlled forces that gently and predictably reposition teeth. The most common appliances used in adult orthodontics are braces and clear aligners.

For those worried about aesthetics, advances in orthodontics have made treatment more comfortable and less noticeable than ever. Many of today’s treatment options are designed to minimize the appearance of the appliance to fit any lifestyle better. This includes clear aligners or different braces treatment options like ceramic braces, which blend into the color of your teeth; self-ligating braces, which can also be ceramic, making them more discreet; or lingual braces, which are mounted on the back sides of the teeth, making them virtually invisible but just as effective.

However, it is important to note that not every type of appliance is suitable for every kind of orthodontic problem, making it essential to be treated by a licensed orthodontist. By working with an orthodontic specialist, you ensure that the right appliance is selected to correct your unique orthodontic issue. Orthodontists have access to the full range of appliance options, and more than anyone else in the dental profession, orthodontists know which appliance is right for an individual patient’s care.

How Long Does Adult Orthodontic Treatment Take?

Adult orthodontic treatment varies depending on the severity and complexity of issues, and each patient will have a unique plan customized for their needs. Your orthodontist will be able to give you a more accurate timeline for your specific treatment during your initial consultation.

However, it is safe to assume that patients with mildly misaligned teeth will take around eight to twelve months, while more complex cases may take a few years to complete treatment. During that time, orthodontist visits are scheduled every six to eight weeks to monitor your progress. It’s a comparatively small investment of time that pays big dividends in improved dental health, jaw function, biting, chewing, dental hygiene, and overall self-confidence.

Just because you’re no longer a child doesn’t mean the opportunity for a healthy, beautiful smile has passed you by. You don’t have to spend the rest of your life hiding your smile. When considering orthodontic treatment, your age doesn’t matter. You can have the smile you’ve always wanted, and it starts with consulting an AAO orthodontist.

Achieve Your Best Smile with an AAO Orthodontist

You can work with an AAO orthodontist to achieve a healthy, beautiful smile at any age. Orthodontists are experts in orthodontics and dentofacial orthopedics – properly aligned teeth and jaws – and possess the skills and experience to achieve your best smile. Find an orthodontist near you and transform your smile.

The post How Old Is Too Old For Braces? Rediscover Your Smile At Any Age appeared first on American Association of Orthodontists.

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A dedicated dentist, teacher, mentor and public servant, John Chope made a lasting contribution to the profession over a remarkable 50-year career.

Dr John Chope passed away peacefully in his sleep at home on 1 August 2026, after a five-month illness with pancreatic cancer.

He graduated from Bristol University Dental School in 1972 after six years of study, which included an intercalating physiology degree. During this period, he studied taste receptors, reflecting an early interest in the scientific foundations of dentistry and medicine.

In 1973, he was employed by the University of Khartoum, where he worked as a senior lecturer in physiology in the Faculty of Medicine. His role involved both teaching and examining medical students.

During his time in Sudan, John also became a co-founder of Khartoum Dental School. He assisted with the establishment and design of the first dental course in Sudan and contributed to its teaching, combining his academic work in physiology with the development of dental education.

On returning to Bristol, John became a senior house officer (SHO) in the oral surgery department. He subsequently worked in general practice in Bristol and Shepton Mallet before opening his own practice in Holsworthy, a small market town in Devon.

Running his own practice required skills that went far beyond clinical dentistry. Out of necessity, John developed not only as a dentist and employer, but also as an engineer, electrician, plumber and builder. These practical abilities became another important part of a working life characterised by wide-ranging interests and skills.

He remained an enthusiastic and dedicated dentist for 50 years, working in his own practices in Holsworthy, Okehampton and Hartland in Devon, and Bude in Cornwall.

Beyond the practice

John’s commitment to dentistry extended well beyond his own practices and communities. Teaching and supporting other members of the profession remained a significant part of his life.

His involvement in education, which had begun during his time in Khartoum, continued throughout much of his professional career, establishing postgraduate teaching for young dentists and mentoring right up until his retirement in 2024.

John also gave many years of service to the wider dental profession. He served on the General Dental Council (GDC) for 17 years and worked for 15 years as an independent medicolegal expert.

He was a National Council member for 16 years, including nine years as chair of the Confederation of Dental Employers (CODE). He was also a National Council member of the Dental Practitioners’ Association (DPA) for six years.

His professional responsibilities extended beyond these organisations. John was an expert professional panel member of the Family Health Services Appeal Authority and the Health, Education and Social Care Chamber of the First-tier Tribunal of the Ministry of Justice for 18 years.

Alongside this extensive professional service, he also served as a magistrate for 25 years, adding another long-standing commitment to public life.

In 2005, John became a member of the external advisory board for the successful Peninsula Medical School dental school bid in national competition, contributing once again to the development of dental education.

His commitment to dentistry also took him overseas later in his career. In 2018, John volunteered as a dentist and dental team leader with a small multidisciplinary clinical team working for the International Health Service charity in remote Honduras.

As well as providing dental care, he took on responsibility as the dental team leader. The majority of the treatment provided during the trip was oral surgery.

Sharing wisdom

John was committed to sharing the knowledge and experience he had accumulated throughout his career.

He gave more than 50 professional talks to dental groups on a wide variety of subjects, with titles ranging from ‘Hypnosis in dentistry’ to ‘That’s a fine mess you got us in! Understanding current GDS crisis’. The breadth of these subjects reflected the wide range of issues that interested him within dentistry.

Writing was another important part of John’s contribution to the profession. Over the years, he wrote more than 150 dental articles, the majority of them for Dentistry magazine and CODE. Together with his lectures and professional talks, his writing provided another means through which he shared his knowledge and views with colleagues.

John’s interests, however, went far beyond dentistry. They included farming, architecture, building, structural design, inventing and sketching.

These interests often had a distinctly practical and creative dimension. He produced his own technical drawings, designed dental and agricultural equipment, and even illustrated his professional talks himself.

John will be remembered for his remarkable contribution to dentistry, his commitment to teaching and mentoring, his many years of professional and public service, and the breadth of interests that accompanied his working life.

Across five decades in dentistry, he remained closely involved with the profession through clinical practice, education, writing, mentoring and service.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

Ahead of her Dentistry Show London 2026 presentation, Emily Lu discusses the growing role of platelet-rich fibrin (PRF) in everyday clinical practice.

Platelet-rich fibrin (PRF) has attracted considerable interest in recent years. What has driven that momentum, and why is it becoming increasingly relevant in everyday clinical practice?

I think it has been driven by a combination of biological appeal, clinical practicality and a growing evidence base. PRF is prepared chairside from the patient’s own blood and provides a fibrin scaffold containing platelets, immune cells and signalling molecules that can support the natural wound-healing process.

It is also relatively straightforward and cost-effective to prepare, which makes it more accessible for everyday practice. However, its growing popularity should not lead us to overstate what it can achieve. PRF is most valuable when used as a biological adjunct in carefully selected cases, alongside sound treatment planning and meticulous surgical technique.

The evidence base for PRF continues to evolve. Where do you think the evidence is strongest today, and where is more research still needed?

Our understanding has become more nuanced. Earlier discussions often focused on the presence of growth factors, whereas we now appreciate that PRF is a three-dimensional fibrin matrix that can support cell migration, angiogenesis and the gradual release of biological mediators.

Clinically, some of the most consistent evidence relates to improved early soft tissue healing and reduced postoperative discomfort, particularly following extractions. There is also encouraging evidence for its adjunctive use in periodontal intrabony defects, ridge preservation and ridge reconstruction procedures, where it may support wound healing and be combined with grafting materials to enhance their handling and biological environment.

However, the evidence is less consistent for some implant-related applications, peri-implantitis and predictable long-term hard tissue gains following ridge preservation or reconstruction. Protocol heterogeneity also remains an important limitation.

We therefore need to distinguish between promising biological mechanisms, improved early healing and evidence of predictable long-term regeneration.

Which patients and clinical situations are most likely to benefit from PRF, and how do you decide when it is the right option?

I tend to think about the clinical indication before thinking about the material. PRF may be particularly helpful when supporting soft tissue healing is a priority, for example following extraction or oral surgery, and as an adjunct in appropriately selected periodontal intrabony defects and regenerative procedures.

The decision depends on the defect anatomy, the patient’s plaque control, smoking status, systemic health, healing capacity and ability to maintain the result. I would also consider whether the patient is comfortable with venepuncture and whether there are relevant medical or haematological considerations.

Most importantly, PRF cannot overcome uncontrolled disease, poor plaque control, unsuitable defect anatomy or inadequate surgical technique. Patient and site selection remain fundamental.

What practical advice would you give clinicians who are considering introducing PRF into practice?

Start with a clearly defined clinical indication rather than purchasing a centrifuge and then looking for situations in which to use it. Undertake appropriate training in venepuncture, preparation and handling, and use a validated protocol consistently.

The whole dental team should understand the workflow. Blood collection, centrifugation, preparation of the clot or membrane and delivery to the surgical site are all time-sensitive. It is helpful to establish a written protocol covering equipment checks, infection control, consent, documentation and the management of complications.

I would begin with straightforward, well-selected cases, record outcomes carefully and avoid changing several protocol variables at once. Consistency is essential if clinicians want PRF to become a predictable part of their workflow.

Your session at Dentistry Show London is titled ‘PRF chairside: translating biology into everyday practice’. Without giving too much away, what practical insights can delegates expect to take back to practice?

The practical message is simple: start with the patient and the clinical problem, ensure the fundamentals of disease control and surgical technique are in place, and then ask whether PRF offers a biological and evidence-based benefit in that particular situation. If delegates can apply that reasoning the next day, rather than seeing PRF as a universal solution, the session will have achieved its purpose.

Want to learn more?

Dr Emily Lu will be joined by Dr Triantafyllio Zafeiri and Dr Aiste Volkyte for ‘PRF chairside: translating biology into everyday practice’ in the Specialty Interest Theatre at 11:15 on Saturday 10 October during Dentistry Show London 2026. Register free of charge at london.dentistryshow.co.uk.

This article is sponsored by Closerstill.

For physicians and health care leaders, the anniversary offers more than a retrospective. It highlights how a medical journal can help translate clinical experience and health system learnings into evidence that is easier to find, cite, and apply.

“Over the course of [the journal’s] existence, so many professionals have been instrumental in its growth and development, and its contributions to health care can be attributed to all who have participated,” wrote G. Richard Holt, MD, the journal’s editor-in-chief, in his latest editorial.

Holt’s message included reflections from others who helped shape the journal, among them Scott Young, MD, of The Permanente Federation and Kaiser Permanente’s Care Management Institute. “The journal’s growth is evident not only in the breadth and rigor of its scholarship, but also in its embrace of digital dissemination,” Young said, pointing to the journal’s numerous advances in indexing, branding, and workflow enhancement.

Milestones in visibility and reach

The journal is indexed in several major medical and scientific databases including PubMed, PubMed Central, Scopus, ResearchGate, and EBSCO. Inclusion in leading indexes is a significant achievement, given the rigorous criteria for acceptance. Further indexing expansions are anticipated. “Where a journal is indexed matters,” said Stephen Parodi, MD, vice president of The Permanente Federation, which publishes the journal. “Indexing status is not only a mark of prestige for a journal, but an important aspect of discoverability for busy clinicians and researchers.”

Related story: What’s causing the physician shortage and how to fix it: The Permanente Journal panel

The Journal, reimagined

In 2021, The Permanente Journal undertook a rebranding effort that included revising its aims and scope, refreshing its visual identity and updating its website. This work positioned the journal as an important venue for scholarly content in value-based care, health care delivery research, and integrated delivery systems, while maintaining its broader role as a platform for clinical research across medical disciplines.

The rebrand — guided by an interdisciplinary steering committee comprised of leaders from all Permanente Medical Groups — was followed by a publishing model change aimed at reducing barriers to participating in scholarship.

Related quality care story: Self-described ‘knowledge-seeker’ leads relaunch of The Permanente Journal

Expanding participation by open access

Although the journal has always been free to read, The Permanente Journal became fully diamond open access in 2023. Under this model, authors retain copyright to their accepted articles and publish under an exclusive license rather than transferring ownership. Importantly, authors pay no publication fees, and accepted articles are published without embargo and are immediately citable from online-first publication.

Recent high-interest articles include “Why Have All the Doctors Gone? Insights Into Early Clinical Departure Among Physicians in the United States: A National Survey” by authors Sea Chen, MD, PhD, and colleagues out of the American Medical Association, and Comparing Kaiser Permanente Members to the General Population: Implications for Generalizability of Research by authors Anna C. Davis et al. Both are among the journal’s most accessed, impactful articles.

The journal has also published expert panel discussions on current challenges in health care and clinical practice, including “Strengthening the Physician Workforce: An Expert Panel Discussion” moderated by Ted O’Connell, MD, and “Moving the Needle Toward True Value-Based Care: An Expert Panel Discussion” led by Nancy Gin, MD, FACP. These and other panels bring together a diverse range of voices to discuss some of today’s most-pressing topics in health care and clinical practice.

Readers have found value in the journal’s release of special sections, such as Improving Health Care Access (2026) and Trauma-Informed Health Care (2024), while those in research communities have cited “Comparing Kaiser Permanente Members to the General Population: Implications for Generalizability of Research” by Elizabeth McGlynn and colleagues over 350 times.

Get all the articles included for the 30th anniversary acknowledgment sent straight to your inbox. Sign up to receive journal alerts from The Permanente Journal.

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• Could virtual reality be the future of agility training and injury prevention?
• Is creatine safe for young athletes?
• When to return to driving following a concussion

Could virtual reality be the future of agility training and injury prevention?

A fascinating new study has produced some very promising findings on the potential of virtual reality (VR) training. The researchers recruited 70 university-level basketball players and divided them equally into two groups: a virtual reality-assisted neuromuscular training group and a conventional neuromuscular training group. Both groups then completed a 12-week training intervention.

The basketball players in the VR-assisted group wore HTC Vive Pro headsets alongside Xsens motion sensors, and their training focused on dynamic balance, reactive agility, plyometrics, and basketball-specific movements. The results were impressive. When agility was assessed following the intervention, the VR-assisted group achieved substantially greater improvements on both the T-Test and Hexagon Test than the conventional training group. The neuromuscular findings were equally encouraging, with the VR-assisted group demonstrating notably greater improvements in reactive strength index (RSI), proprioceptive accuracy, and dynamic knee valgus.

One particularly interesting advantage of VR training is its ability to provide athletes with immediate feedback while they are actually performing a movement. By detecting changes in joint positioning, the technology can provide instant visual and aural feedback, allowing athletes to identify and correct movement issues in real time.

So, could virtual reality become part of the future of agility training and injury prevention? Based on the findings of this study, that possibility no longer seems particularly far-fetched. However, while the improvements in agility and several injury-related biomechanical measures are certainly promising, the study did not measure actual injury rates. Therefore, considerably more research is needed before VR training can be considered an effective injury-prevention strategy.

If you would like to learn more about VR training, check out our blogs Virtual reality for sports training: How VR can help pro and amateur athletes (and fans) and  Virtual reality for sports training: Can VR help athletes?

Is creatine safe for young athletes?

Leading sports and exercise scientist Paul Hough published an insightful post on LinkedIn regarding young athletes and their use of creatine. He reviews the current evidence surrounding creatine supplementation in this population based on existing literature.

Hough notes that while evidence on creatine use in children and adolescents is limited, the available research suggests that it is generally safe. According to the studies, a dosage of 0.1 to 0.3 grams of creatine per kilogram of body mass per day is considered safe. However, there is very little research on the effectiveness and safety of higher doses. Some individuals may employ a rapid loading phase, taking 0.3 g/kg four times daily for a week to quickly increase muscle creatine stores. Hough warns that this approach may lead to a higher risk of gastrointestinal discomfort.

Worryingly, Hough highlights research indicating that only 11% of young athletes could answer questions about creatine use correctly. This finding raises concerns about the potential misuse of creatine among young athletes and underscores the need for proper education and adult supervision if young athletes are taking creatine.

While more concrete evidence is needed on the effectiveness of creatine and appropriate supplementation guidelines for young athletes, Hough concludes his post by emphasising that young athletes should prioritise consistent training, sound nutrition, and adequate sleep before even considering taking creatine. This is undoubtedly the most important message.

When to return to driving following a concussion

A highly practical new study has shed light on the often-overlooked issue of driving after a concussion. The research involved 49 young adults who had been diagnosed with a concussion within the past 12 days. Each participant took part in a simulated driving assessment.

The findings revealed a clear trend: the closer the participants were to the day they suffered the concussion, the poorer their driving performance was. Interestingly, driving skills improved as more days passed since the injury, indicating that recovery happens gradually during the first couple of weeks post-concussion.

While return-to-play protocols for athletes have improved, protocols for returning to driving are often neglected. Based on this study’s results, it’s advisable to limit driving for at least the first 24 to 72 hours following a concussion. After that initial period, individuals should follow a gradual return-to-driving approach rather than jumping back in immediately.

From us this week:

>> New course: Micronutrients for Athletes
>> New podcast: Why Athletes Keep Breaking Down
>> New infographic: Sleep Hygiene Protocol
>> New article: Hydrotherapy

Access to a growing library of sports science courses

SFS Academy is an all-access membership to premium sports science education.

With SFS Academy, you’ll learn from some of the best coaches around the world as they teach you how to apply the latest research and practice with your athletes.

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Buying Medical Equipment

Pros

• You own the equipment which becomes an asset of the practice.
• Once it’s paid off you can continue to utilize the equipment without payment.
• You will have more freedom to move, modify, or dispose of the equipment.
• If you decide to upgrade to a different piece of equipment, you might retain better resale value.
• Depending on your business structure and current tax rules, you might qualify for deductions and depreciation.

Cons

• Upfront cash most likely will be required and might impact your working capital.
• Without purchasing a service contract, maintenance and repairs will become your responsibility.
• Technology might become outdated while you still own the equipment.
• If your practice grows, changes specialties, or moves locations you will have less flexibility.
• Capital might not be available in other areas such as payroll, marketing, inventory if it’s tied up in the purchase of equipment.

Leasing Medical Equipment

Pros

• You will be able to preserve your cash flow without making a large initial investment.
• Will free up money to make other purchases that the practice might need.
• Monthly budgeting will be more predictable.
• May become easier to upgrade if technology changes rapidly.
• Maintenance and service contracts might be included depending on the type of lease.

Cons

• Cost of the life of the equipment can cost more.
• Contract terms can be complicated.
• You will have committed to monthly payments even if the equipment isn’t being used as initially anticipated.
• You don’t necessarily own the equipment.
• Return/upgrade fees might be impactful depending on the terms of the lease.
• Tax impact can vary depending on your lease, so a CPA would need to review.

Contact Us

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Tim Doswell reflects on the stark financial reality of supply-cost drift, explaining how unexamined overhead compounds into a devastating penalty when a buyer calculates your EBITDA.

Practice valuation is a function of earnings before interest, taxes, depreciation, and amortisation (EBITDA), and EBITDA is a function of overhead. Most of us focus on the wrong end of that equation for 15 years, and then a buyer’s accountant gets a closer look at our cost base than we ever did.

There is a moment that most principals experience only once, and almost always in retrospect. It is the moment you realise that a buyer has formed a clearer view of your practice’s cost base than you ever did, and has priced that view into their offer, without you ever seeing their workings.

The practice sale process

Earlier in the process, your accountant will have pulled together calculations of past and forecast EBITDA for the information memorandum that goes out to market.

By that stage, the cost base is what it is. There is not much remedial action you can take at that point that would meaningfully change the multiple.

And in many cases, the timeline to sell is not yours to decide. It is dictated by health, family circumstances, partnership issues, or simply the year you have settled on for personal reasons. The luxury of saying, ‘I will sell when my consumable costs are optimised’ is one most principals never have.

What I want to share is what I now wish I had understood about that ordinary, unremarkable corner of the business in the years before any of this became relevant.

Not because anyone is doing anything wrong, but because the maths of how supply costs translate into practice value is much less forgiving than most of us realise, and the window for doing something about it is much longer and earlier than I appreciated.

The number that quietly compounds

Industry analysis suggests that supplies and lab fees account for six to nine percent of gross revenue at a typical UK practice, depending on size and treatment mix.

For a practice collecting £800,000 a year, that is somewhere between £48,000 and £72,000 annually, before lab work is even considered.

Within that figure sits something that I now think of as the silent line item. It is the gap between what you are actually paying for your supplies and what comparable practices are paying for the same things.

Some of that gap is genuine market movement. Some of it is drift, which is what happens to prices in any market where buyers have no comparison data.

Drift is not dramatic. It is a few per cent on a composite syringe one year, a product code that gets quietly replaced the next, a promotional rate that expired 18 months ago and that nobody noticed reverting. Each change is too small to challenge.

The cumulative effect, across a few hundred regularly ordered line items, is a different matter.

Research from dental procurement analysts has found price variations of up to 30% for identical products between practices, depending on the supplier relationship and the timing of the last negotiation. Most of that variation is invisible to the practices experiencing it.

Why this is a valuation issue, not just a margin issue

Here is the part I genuinely did not appreciate while I was running my practice.

Dental practices in the UK trade on EBITDA multiples that vary by buyer, structure, and circumstance, but generally sit somewhere in the region of six to nine times. The exact number depends on factors specific to each transaction.

The principle, however, is constant. Every pound of recurring overhead in your practice is not just a pound off this year’s profit. It is several pounds off your eventual sale value.

The arithmetic is straightforward but worth pausing on. A practice spending £4,000 a month on consumables, with 15% of that figure sitting above market rate, is overspending by roughly £7,000 a year. At a seven times multiple, that is nearly £50,000 removed from the practice’s eventual sale value.

At a higher multiple, the figure is larger. And that is for one category of overhead, on a relatively modest spend, with a drift figure I would describe as middle of the road, based on what is now becoming visible across the industry.

The number is not the point. Multiples vary, drift varies, and every practice differs. The point is the structural relationship between cost discipline and valuation.

Every pound of unnecessary overhead you carry is multiplied into the price you eventually receive, in the wrong direction.

The hard lesson is that this multiplier works whether you know about it or not. The practices being acquired today are being valued by buyers who do know about it, and whose accountants are perfectly capable of doing this analysis themselves.

By the time it surfaces in due diligence, the principal has lost the chance to do anything about it.

Why careful people miss this

Nothing about price drift is the fault of the principals it happens to. The way prices move in this market is specifically designed to sit below the threshold of attention.

A composite syringe goes from £18.50 to £19.80 to £21.40 over three years. Each step looks like inflation. None of them is large enough on its own to question.

But the cumulative move is around 16%, which is roughly double what general dental inflation has been doing over the same period. You would only know that if you had a benchmark, and most of us never have.

There are several mechanisms involved, none of them sinister. Products get discontinued and replaced by new models with a different code at a higher price, so no like-for-like comparison is possible. Promotional rates quietly expire when you open an account, and the standard rate applies.

A box of 200 gloves becomes a box of 180, and the unit cost rises, even though the invoice never shows a price change.

Or, most commonly, your supplier gradually edges your price up because the longer you have been a customer, the less likely you are to switch.

None of this is dishonest. It is rational commercial behaviour in a market without price transparency. Every industry without price transparency works the same way.

Energy did, before comparison sites. Insurance did. Telecoms did. Dentistry, until very recently, has had no equivalent.

What I would do differently

The point of what follows is not that every principal should be preparing for sale. Most of the principals reading this will not be selling for years, and some never plan to.

The exercise is worth doing regardless, because the same cost discipline that protects your valuation also protects your monthly margin, your associate pay pool, and your capacity to invest in the practice.

The valuation argument is one of several reasons. It just happens to be the one with the largest number attached to it.

If I were earlier in my career as a principal and looking at this fresh, I would spend a focused afternoon on the exercise below. It does not require software, although software now exists that does this continuously rather than as a one-off.

This exercise will not give you a complete picture, because true benchmarking requires comparing your prices against what other practices actually pay across a sample large enough to be statistically meaningful. But it will tell you whether the problem is real and roughly how much you are dealing with.

A note on suppliers

It’s worth being direct about this, because it matters.

Drift is not evidence that suppliers are doing something wrong. It is evidence that any market without transparency produces the same outcome over time. Prices trend upward when nobody is checking.

The vast majority of dental suppliers operate in good faith, with their own rising input costs and their own competitive pressures to manage. Greater transparency works in their favour, too.

Suppliers who price fairly and consistently have nothing to fear from comparison. The only people disadvantaged by visibility are those who depend on its absence, and in my experience, that is rarely the kind of relationship that serves a practice well in the long run.

The takeaway

If there is one thing I want a principal reading this to take away, it is the multiplier and the timeline. Every pound of unnecessary overhead in your practice is not a pound.

It is six to nine pounds, depending on what your buyer pays for EBITDA. And the time to act on that figure is years before any sale becomes a live conversation, because by the time it is a live conversation, your accountant is already preparing the information memorandum, and your options have narrowed.

Supply costs are one of the few overhead categories where you have meaningful room to optimise. The market largely sets staffing. Premises are what they are. But what you pay for supplies is variable, negotiable, and historically rarely audited.

The dental profession has been operating without the kind of pricing transparency that consumer markets have taken for granted for years.

That is starting to change, partly through tools that benchmark anonymised invoice data across practices, and partly through principals deciding that this is overdue attention. Either way, the question is not whether drift is present in your practice.

Statistically, it almost certainly is. The question is whether you would prefer to address it on your own timeline or face its consequences in an offer letter priced by someone who saw what you did not.

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The number of dental technicians on the UK register has fallen for the sixth consecutive year, despite the overall dental care professional register growing by almost 5%.

Annual renewal statistics from the General Dental Council (GDC) showed that 84,746 dental care professionals (DCPs) were registered in 2026, an increase of 3,746 compared with the equivalent point last year.

However, dental technician numbers fell from 4,895 to 4,824, continuing a decline that has prompted concerns about training and the future capacity of UK dental laboratories.

Laboratory editor-in-chief Matt Everatt has suggested that the decline in the dental technology workforce was due to a number of factors including training programmes under financial pressure, unregulated manufacturing, and the impact of new technology.

A total of 3,769 DCPs were removed from the register following the annual renewal period. Due to ongoing problems with the MyGDC portal during this renewal period, the GDC said that DCPs who were having technical issues would not be removed from the register provided they contacted the regulator before the deadline.

Dental workforce demographics

Dental nurses remain by far the largest DCP group, with 69,824 registered – up from 65,797 in 2025. Additionally, the number of dental hygienists increased to 11,407 from 11,065 in 2025.

The dental therapy profession has seen significant growth since 2023. In three years, the number of dental therapists has increased from 5,558 to 8,824. Many of these were from internationally qualified dentists who joined the register with DCP titles, a route that the GDC has now closed. 

Since 2025, the government has called for greater use of the wider team in NHS dentistry, particularly by helping dental therapists work to the ‘top of their clinical potential’.

Training capacity for dental therapists is also being significantly expanded through new courses and facilities.

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A planned Phase IIa trial of an experimental tooth-regeneration drug will involve 24 children with severe congenital tooth agenesis, Toregem BioPharma has said.

The Japanese biotechnology company said the Pharmaceuticals and Medical Devices Agency (PMDA) had completed its investigation of the clinical trial notification for a tooth regrowth medicine called TRG035.

Toregem said the study must now undergo institutional review board assessment before it can begin enrolling participants and administering the investigational drug. Toregem did not announce a proposed start date for the Phase IIa study.

The open-label, non-comparative, multicentre study will investigate dosing in children with severe congenital tooth agenesis. It would move testing of TRG035 from healthy adults into patients with the condition the drug is intended to treat.

TRG035 already tested in adults

TRG035 has already undergone human testing in a Phase I study at Kyoto University Hospital, which began in October 2024.

The registered study had a target sample of 30 healthy adult men aged between 30 and 64 who were missing at least one molar. It was a randomised, double-blind, placebo-controlled dose-escalation study designed primarily to assess safety.

Toregem said Phase I confirmed the drug’s safety, although detailed results have not been made publicly available.

In June, Toregem BioPharma announced it had raised US$5.3 million to support the next stage of development.

The study forms part of wider research into whether tooth regrowth could eventually become possible in adults, although Toregem’s current clinical programme is focused on congenital tooth agenesis in children.

How is TRG035 intended to work?

TRG035 is an antibody treatment designed to block USAG-1, a protein involved in suppressing tooth development. Toregem hopes this will allow dormant tooth buds to develop and form new teeth.

The company has reported positive findings in animal models, but TRG035 has not yet been shown to regenerate teeth in humans.

Toregem said: ‘If administration of TRG035 enables tooth formation, patients will be able to eat using their own teeth throughout their lives.’

Its initial development is focused on severe congenital tooth agenesis. The company ultimately hopes to investigate whether the treatment could address teeth lost through dental decay and periodontal disease, but this remains a longer-term ambition.

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Consultant orthodontist and researcher Dr Farnaz Parvizi explores how a formal patient complaint can impact clinicians, from wellbeing to professional identity, and the role workplace culture can play in helping them cope.

Consultant orthodontist and researcher Dr Farnaz Parvizi has spent the last few years studying one of the most universal yet least discussed experiences in clinical practice: what really happens to a clinician when they receive a formal patient complaint? Her session at BOC 2026 in Brighton promises to be one of the most honest and personally relevant discussions at this year’s conference.

Ask any orthodontist about patient complaints and you will not have to wait long for a story. Almost everyone in clinical practice has been through one, or knows someone who has, and most will tell you it was one of the most difficult experiences of their professional life. Yet, for all its familiarity, the formal complaint remains one of the least studied areas in dentistry. Very little rigorous work has been done to define it, measure it or understand how it impacts clinicians’ wellbeing.

Dr Farnaz Parvizi is trying to change that.

How do orthodontists experience a formal complaint?

Now in the fourth year of a PhD funded by the British Orthodontic Society Foundation, Dr Parvizi is developing a theoretical framework for understanding how UK orthodontic clinicians experience formal complaints and what role workplace factors play in shaping those experiences. The research grew out of her own career, her work with trainees, and a conviction that the profession deserves something more substantive than the acknowledgement that complaints are simply stressful.

‘Like many of my colleagues, I have been subject to formal complaints,’ she says. ‘I knew how it made me feel; the emotional impact; the responses; the behaviours. I was interested to find out how it was for everyone else. It is one thing knowing it about yourself, yet we do not really know the impact it has on us as a collective.’

Turning experience into research

Dr Parvizi qualified from the University of Bristol, completed her orthodontic training in Birmingham and spent eight years in specialist practice, including a year in Australia. On her return, she pursued further training, secured a consultant post and has remained closely involved in teaching and education ever since. She is currently a consultant orthodontist at the Royal United Hospitals Bath and an honorary senior lecturer at the University of Bristol. A master’s degree in education, completed in 2019, gave her the appetite for a PhD. BOS Foundation funding has allowed her to have protected research time away from her clinical responsibilities. She is keen to highlight that support because she suspects many colleagues do not know it exists.

‘A lot of people have ideas but think they cannot access the funding, or that it is not for them,’ she says. ‘It absolutely is. If you have a question you want to answer, find out what support is available. You might be surprised.’

More than just stressful

At the heart of Dr Parvizi’s research is a distinction that will feel familiar to anyone who has been through the process: the difference between stress and threat.

‘In a regulated profession, a formal complaint is never just an uncomfortable experience. It challenges our professional credibility, how others see us, and our professional identity, how we see ourselves. In addition, there is always the risk of escalation and loss of one’s ability to practise. The possibility of losing your registration to practise means that formal patient complaints are no longer just a stress but a threat – and that is a very different thing.’

Having completed the qualitative phase of her study, involving in-depth interviews with orthodontic clinicians, Dr Parvizi has identified six domains that together define the complaint experience, including the cognitive burden of carrying a complaint, regardless of its severity, the way its effects can extend into other parts of life, and challenges to professional identity and moral values. All of these outcomes are influenced by workplace factors that either exacerbate or buffer the impact of formal complaints.

‘If the clinicians’ basic psychological needs are frustrated in the workplace, formal complaints will have a more pronounced impact on their wellbeing. People begin to doubt their own abilities. They withdraw. They become more cynical. Their productivity falls. Absenteeism increases. These are the downstream markers I will be looking at in the survey.’

What your workplace has to do with it

Dr Parvizi’s research focuses on workplace factors that she believes are especially important. The first is psychological safety: whether clinicians feel safe enough within their teams to acknowledge mistakes and ask for support without fear or blame. The second is organisational justice: when a complaint process begins, do clinicians feel it is handled fairly? Are they respected, involved and kept informed, or does the process feel opaque and out of their hands?

‘In aviation and in nuclear industries, psychological safety is well understood,’ she says. ‘But we have never actually looked at it in our own workplaces. Safe teams are teams that learn from mistakes. That is the culture we should be building.’

She is also clear that seniority offers no immunity. If anything, she suggests, the stakes can be even higher for those further along in their careers. ‘When that complaint comes through, you will experience the same dimensions as your trainees would,’ she says. ‘It does not matter who you are or where you sit in the hierarchy.’

A chance to take part

The next phase of Dr Parvizi’s research will build on her interview findings through a large-scale survey, extending the project to a broader group of orthodontic clinicians. Dr Parvizi hopes that delegates at BOC 2026 will be able to take part directly and plans to provide a QR code to direct them to find out how after the session. It is an exciting stage in a study that has the potential to shape how the profession understands and supports clinicians facing formal complaints.

For those wondering whether a session on complaints is really worth their time at a conference full of clinical content, Dr Parvizi’s view is straightforward. ‘It does not matter what technique you use, what grade you are, or how long you have been qualified,’ she says. ‘If you have ever received a complaint and wondered why it hit you as hard as it did, this session is for you. For the first time, someone is trying to properly understand what that experience involves. And that work starts with you being in the room.’

The British Orthodontic Conference takes place from 24 to 26 September 2026 at the Brighton Centre. Dr Parvizi’s presentation, ‘How do UK orthodontic clinicians experience formal patient complaints and what roles do workplace factors play in shaping their experiences?’ will offer delegates the chance to engage with an issue that cuts across every stage of clinical practice.

Book your place and see the full programme here.

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The Aligner Dental Academy presents a five-step guide to getting the most of your Invisalign cases and building clinical confidence.

Many Invisalign clinicians find that one of the biggest hurdles to treating more complex cases isn’t the treatment itself, it’s having the confidence to critically review and optimise the ClinCheck before treatment begins.

ClinCheck should not be regarded as a polished animation that simply requires approval. It is a clinical prescription and must reflect the patient’s diagnosis, facial aesthetics, periodontal health, restorative objectives, and functional requirements.

A reliable review process begins by defining the intended final tooth positions before assessing the digital setup. Each ClinCheck should then be evaluated systematically against these predetermined treatment goals.

Begin with a comprehensive assessment and clear treatment objectives

Before reviewing the first ClinCheck, complete a thorough clinical assessment using photographs, radiographs, intraoral scans, and appropriate occlusal records. Identify the patient’s primary concern and translate it into specific, clinically achievable treatment objectives.

These objectives provide a benchmark against which the digital treatment plan can be assessed. They also support clear communication with the patient and contribute to a robust consent process.

The Aligner Dental Academy’s Five-Step ClinCheck Review provides a structured framework for assessing ClinCheck plans.

Step one: product and feature selection

Whether you are a GO or Comprehensive provider, the first thing to do is to check that the product type you have selected is able to meet your patients treatment goals. For example if your patient speficially wants to have a wide smile, then ensuring the plan is on GO plus can help deliver that as you can expand to the first molar.

Step two: review bite and technicians comments

Verify the accuracy of the starting occlusion

Even the most sophisticated digital setup has limited value if it begins from an inaccurate representation of the patient’s bite.

Compare the initial digital occlusion with the clinical photographs, intraoral scan, and occlusal records. Pay particular attention to: occlusal cant, mandibular deviation, facial asymmetry, dental midlines, posterior intercuspation, arch relationships, overjet and overbite.

Orientate the ClinCheck model to correspond with the clinical photographs so that the comparison is meaningful and consistent.

Review the technician’s comments before proceeding. These may highlight incomplete records, unclear instructions, or limitations associated with the requested movements. Confirm that an adequate proportion of the occlusal surface of the most posterior teeth has been captured, as incomplete scan data may compromise the accuracy of the digital occlusion.

Step three: assess the proposed final position against the prescription

Evaluate the proposed endpoint before becoming absorbed in the animation. The final setup should resolve the patient’s presenting concern while remaining consistent with the agreed aesthetic, periodontal, restorative, and functional objectives.

A useful framework is the four-sentence prescription, which defines four key reference points:

1. The patient’s presenting complaint
2. The desired position of the upper anterior teeth
3. The intended upper posterior position and arch form
4. The desired lower incisor position, overjet, and overbite.

This approach describes the intended endpoint in clear, familiar, and facially driven language before the automated setup is reviewed.

Begin with the upper central incisors. Their inclination, vertical position, and relationship to the smile line influence the overall aesthetic result. Assess whether the planned intrusion or extrusion will improve tooth display and the smile arc, and confirm that the upper dental midline has not shifted unintentionally.

Next, evaluate the upper posterior reference point and proposed arch form. Expansion should be purposeful and supported by the diagnosis rather than accepted as an automatic feature of treatment.

Finally, assess the lower incisors carefully, particularly in patients with a thin gingival phenotype, reduced periodontal support, or pre-existing recession. Excessive proclination or buccal movement may create avoidable periodontal risk.

The Aligner Dental Academy’s guide to the four-sentence treatment plan provides a practical framework for modifying ClinCheck plans.

Use the available visual assessment tools

Superimposition is particularly valuable for identifying the magnitude and direction of planned tooth movement. Compare the initial and final positions from both occlusal and lateral perspectives.

Grid tools can assist in estimating movement, while in-face smile visualisation may support assessment of: incisor position, smile arc, tooth display, dental midlines and facial integration.

These tools are important because a final digital model may appear well aligned while still containing undesirable expansion, unnecessary round-tripping, or unfavourable changes in incisor inclination.

Step four: review the complete sequence of tooth movement

Once the proposed endpoint is acceptable, examine how the software intends to achieve it.

Play the animation from beginning to end and look to ensure the final position is meeting the upper and lower anterior reference point and the posterior reference point. In addition look for the following movements:

• Round-tripping
• Excessive simultaneous movement
• Loss of anchorage
• Unfavourable sequencing
• Unnecessary expansion or proclination
• Potential occlusal interferences.

Consider whether additional auxiliaries, such as elastics, bite ramps, or attachments, may be required.

Review the tooth movement table and identify movements that may be biologically demanding or less predictable. ClinCheck displays prescribed movement; it does not guarantee biological expression. Difficult rotations, extrusion, intrusion, torque, and root movement therefore require particular scrutiny.

A common error is to assess only the final position without reviewing the sequence through which that position is intended to be achieved.

Audit interproximal reduction carefully

Do not accept prescribed interproximal reduction automatically. Review the amount, location, distribution, and timing of all planned IPR.

The Aligner Dental Academy recommends limiting IPR to approximately 0.3 mm per anterior contact and up to 0.5 mm per posterior contact. These values should nevertheless be adapted to the patient’s dental anatomy, enamel availability, periodontal condition, and clinical access.

IPR may also be used strategically. For example, lower-arch IPR may facilitate lower incisor retraction and increase overjet, whereas upper-arch IPR may assist in reducing excessive overjet.

Consider tooth morphology, contact-point position, and the risk of black triangles. Space creation and distribution should support the intended aesthetic, restorative, and occlusal outcome rather than merely resolve crowding numerically.

Protect the final occlusion

Confirm that the proposed overjet and overbite are functional, atraumatic, and compatible with any planned or existing restorations.

Maintain adequate overjet, commonly at least 2 mm, to reduce the risk of an unfavourable anterior relationship.

Remain alert to the risk of posterior open bite. Excessive anterior contact, poor arch coordination, unsuitable staging, and inappropriate single-arch treatment may all compromise the final occlusion.

Single-arch treatment should be considered only when arch coordination, function, overjet, and overbite can be maintained predictably. Where these relationships cannot be preserved, dual-arch treatment may offer a safer and more reliable approach.

Step five: conclude with informed consent and precise communication

Before approving the plan, revisit all case-specific consent considerations, including: gingival recession, black triangles, IPR, tooth-shape limitations, difficult or less predictable movements, potential occlusal changes, treatment duration, retention requirements, additional costs, the possible need for refinement, treatment costs etc.

Where modifications are required, use 3D Controls alongside concise and specific written instructions. The four-sentence prescription can be included within the modification request to provide the technician with a clear description of the intended endpoint.

The following Aligner Dental Academy webinar discusses effective communication with the ClinCheck technician.

When the revised setup is returned, verify each requested change individually. Do not assume that all instructions have been interpreted or incorporated correctly.

Conclusion

A consistent ClinCheck review is an extension of diagnosis and treatment planning, not a separate administrative step. By combining a facially driven prescription with a structured review process, clinicians can identify errors earlier, communicate more effectively, and deliver treatment that is safer, more efficient, and better aligned with the patient’s clinical needs and expectations.

This article is sponsored by the Aligner Dental Academy.

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Complex care pathways could improve care for patients with high levels of disease, says Ian Gordon, but questions remain over prevention, remuneration, clinical complexity, patient disengagement and the financial risk transferred to NHS dental practices.

In a previous article, I explored the clinical rationale, operational reality and practical risk underpinning the decision to use or not implement clinical care pathways. I’d now like to consider the wider practical limitations of complex care pathways: clinical complexity, financial sustainability, professional judgement and risk transfer to providers.

The concerns about complex care pathways are not limited to Compass reporting, declarations and patient charging. There are wider questions about whether the model properly reflects the clinical complexity, time, cost and risk involved in treating high-need patients in NHS general dental practice.

Prevention must remain central, whatever the payment model

One important risk is that the debate becomes too focused on whether care is delivered through a complex care pathway or a conventional banded course of treatment. Preventive care and risk factor management must remain integral to both.

If a patient is treated through a banded course rather than a pathway, that should not be interpreted as reducing the need to address diet, oral hygiene, fluoride use, smoking, alcohol, plaque control, diabetes control, xerostomia or other relevant modifiable risk factors. Prevention is not optional simply because the payment mechanism changes.

This is clinically and medico-legally important. If a patient later deteriorates, or complains that disease progression was not properly addressed, the question will not only be whether the correct NHS claim was made. It will also be whether the clinician assessed risk, gave appropriate preventive advice, delivered relevant interventions and recorded those discussions.

The remuneration may not reflect the service requirements

The service requirements for CCPs are extensive. They require assessment, diagnosis, staging and grading, risk factor identification, personalised care planning, preventive advice, ongoing review, documentation, declarations, and completion or exit management. That is before considering the operative treatment itself.

There is a legitimate concern that the current remuneration does not adequately reflect the level of work required. The pathway tariff may look more substantial than a conventional banded claim, but the clinical and administrative requirements are also much greater. For some practices, particularly where high-need patients require multiple visits, DCP input, extended review and close monitoring, the pathway may be difficult to deliver sustainably.

That matters because an underfunded pathway can create perverse incentives. If the model is not economically viable, practices may be reluctant to use it, clinicians may disengage, or the pathway may be delivered in a way that technically satisfies the claim but does not fully realise the intended clinical benefit.

Very high treatment need is not sufficiently recognised

The pathways are intended for patients with more complex disease, but they do not appear to scale adequately with the extent of disease burden. A patient with five carious teeth may meet the entry threshold for a caries pathway, but so might a patient with seven, ten or more carious teeth. Those patients may require substantially different levels of clinical time, treatment planning, operative care, prevention, stabilisation and review.

The same point applies to periodontal and combined caries/periodontal cases. There is a significant difference between meeting an eligibility threshold and presenting with very extensive disease requiring prolonged, staged intervention.

This creates a practical limitation in the design. A fixed pathway tariff may not adequately recognise the upper end of complexity. The risk is that patients with the greatest need may be the least financially viable to treat under the pathway model, even though they are precisely the cohort the reform is intended to support.

Non-carious treatment need is under-recognised

The guidance necessarily focuses on caries and periodontal disease because these are the main clinical entry routes into the pathways. However, many patients in this cohort also present with significant non-carious treatment needs: fractured teeth, heavily restored teeth, failing restorations, tooth wear, broken cusps, defective margins, compromised occlusion and complex restorative decision-making.

These issues are not incidental. In real practice, stabilising a high-need patient often involves managing both active disease and the consequences of previous restorative history. Broken or heavily restored teeth can be time-consuming, technically challenging and costly to restore, even where they are not simply ‘carious teeth into dentine’ for pathway-entry purposes.

If the pathway design does not properly recognise this broader restorative complexity, it risks underestimating the work required. It may also create disagreement about what is included within the pathway, what should be claimed separately, and what the patient should reasonably expect to receive.

Financial risk is disproportionately transferred to practices

A further concern is that pathways may be clinically front-loaded. In many cases, the assessment, diagnosis, urgent stabilisation, prevention planning and much of the operative intervention will take place early in the pathway. If the patient then disengages, fails to attend or becomes unable to continue, the practice may already have incurred a substantial proportion of the clinical time and cost.

The pathway cannot simply be unwound. If the patient does not complete the pathway, the practice still has to manage the declarations, incomplete pathway rules, patient communication, any complaint risk and the clinical consequences of partially completed care.

This transfers a significant element of risk to providers for factors that may be outside their control. High-need patients may be more likely to have irregular attendance, social barriers, anxiety, competing health problems or difficulty engaging over six or twelve months. These are precisely the patients the model is designed to help, but they are also the patients most likely to create completion and financial risk.

A fair model needs to recognise that risk. Otherwise, practices may reasonably hesitate before commencing pathways for the very patients who could benefit most, particularly where early treatment costs are high and later patient engagement is uncertain.

Prescriptive requirements may affect clinical flexibility

Standardisation can be helpful. It can support consistency, reduce inappropriate variation and give practices a clearer structure for managing complex disease. However, there is a balance to be struck.

If service requirements become too prescriptive, there is a risk that clinicians feel they are delivering a contractual pathway rather than exercising professional judgement for the individual patient. Patients do not always respond predictably. Their attendance, motivation, disease activity, social circumstances and treatment preferences may change over time. A pathway model needs enough flexibility to accommodate that reality.

The concern is not that clinicians should be free from accountability. It is that contractual requirements should support clinical judgement, not replace it. The records should show why decisions were made, how the patient responded, and why care was adapted. That is preferable to a rigid process in which compliance with the pathway becomes the dominant objective.

Summary of additional risks

Overall conclusion

The success of complex care pathways will depend not only on whether the clinical rationale is sound, but on whether the model is practical to deliver in NHS general dental practice.

A workable system must preserve prevention across all courses of treatment, recognise the full range of clinical complexity, fund the time and documentation required, allow appropriate clinical flexibility, and avoid transferring disproportionate financial risk to practices where patients disengage.

It is therefore reasonable for the profession to support the ambition of better care for high-need patients while remaining critical of the current mechanics. The question is not whether prevention, stabilisation and risk management matter. They clearly do. The question is whether the pathway structure, reporting systems and remuneration model are sufficiently robust to deliver those aims safely, fairly and sustainably in real practice.

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Christian Darnell explores the often-overlooked financial implications of moving from NHS to private dentistry, and why dentists should prioritise replacing pensions and protection benefits from day one.

Given the changing landscape of primary care dentistry in recent years, many practices across the UK have moved away from NHS contracts and transitioned into fully private models.

For many dentists, this shift is driven by greater autonomy, improved financial sustainability and more lifestyle flexibility. But practice revenue is only part of the picture.

Transitioning from NHS to private practice also means giving up a range of benefits that are often overlooked in the early stages of the process. Financial advisers commonly refer to these collectively as the ‘basket of benefits’ – and replacing them should be treated as a priority, not an afterthought.

What dentists often miss when leaving the NHS

For dentists moving into private practice, the emphasis is understandably on business cashflow and clinical continuity. Yet a common behavioural risk can emerge at this point – pension contributions are often delayed.

The reasoning is familiar: ‘I’ll restart my pension once things settle.’ In practice, those delays can become prolonged and financially significant.

The issue isn’t simply lost contributions. It’s lost time in the market. And time, once gone, cannot be recovered.

Even if contributions are increased later, the compounding growth that would have occurred in the intervening years cannot be retrospectively recreated.

That distinction is often underestimated. Two dentists can end up with very different retirement outcomes despite contributing similar amounts overall, simply because one started earlier.

Additionally, protection planning often takes a back seat during the transition to private practice. Income protection, life cover and critical illness insurance are frequently postponed until the business feels more established.

Yet periods of change can also be when financial resilience matters most, making it important to review existing arrangements and ensure cover remains appropriate.

The compounding effect of delay

Private pensions operate differently from the NHS Pension Scheme (NHSPS). While NHS benefits are defined and linked to career earnings, private pension provision relies on investment growth in underlying assets, typically diversified funds.

This introduces a critical factor: compounding.

Growth is generated not only on contributions, but also on previously accumulated growth. For example, if a portfolio grows by 5% in one year and 10% the next, the second year’s return is applied to a higher base (including the gains from year one).

Over time, this creates a snowball effect. But equally, it means that even short delays in starting or restarting pension contributions can increase the monthly cost required to achieve the same retirement outcome.

In practical terms, a contribution level that might have required £300 per month at the point of transition could increase significantly if deferred for even a couple of years.

The most effective approach is consistency from day one of private practice. If the transition occurs on 1 January, pension saving should ideally begin in that same month. This ensures continuity of long-term planning and preserves the full benefit of compounding over time.

Replacing the wider NHS ‘basket of benefits‘

A key misunderstanding among many dentists is that the NHS pension is solely a retirement savings vehicle. In reality, it also includes a suite of embedded protections that are often underestimated until they’re lost.

These typically include:

Spouse’s and dependants’ pensions

The NHSPS provides ongoing income for a spouse or civil partner after death, alongside dependants’ pensions for eligible children (typically up to age 23 if financially dependent). These benefits provide long-term income security that extends beyond the individual member.

Death in service benefits

In many cases, a lump sum is payable on death in service, broadly calculated as a multiple of pensionable earnings, alongside ongoing survivor benefits.

Ill health retirement provisions

The NHS scheme includes tiered ill health retirement benefits, which may provide early access to accrued pension benefits if a dentist is permanently unable to continue working. In more severe cases, enhanced benefits may apply based on projected service to retirement age.

Sick pay arrangements

NHS dentists typically benefit from structured sick pay, including full pay for an initial period followed by reduced pay for a defined duration, subject to service terms. This creates a material income safety net during periods of short to medium-term illness.

Taken together, these form a significant protection framework – one that doesn’t automatically exist in private practice unless it is actively replaced.

Importantly, what often changes aren’t just the benefits themselves, but the responsibility for securing them. In the NHS, much of this framework exists as part of the employment structure.

In private practice, dentists must actively decide what to put in place, when to do it and how it integrates with their broader financial planning. That shift in decision-making responsibility is often underestimated during the transition.

How private arrangements can replicate NHS protections

The good news is that these benefits are not lost permanently when leaving the NHS. But they do need to be deliberately rebuilt.

A direct pension replacement is one route. However, many dentists also combine pension saving with dedicated protection policies to replicate the broader safety net.

For example, life cover can replace death-in-service lump sums, while Family Income Benefit policies can mirror the structure of spouse and dependants’ pensions by providing regular monthly income rather than a single lump sum payment.

This distinction is important. While lump sums can be useful, many households are more naturally structured around income flow. A monthly benefit (such as £5,000 per month for a defined period) can be easier to integrate into ongoing living costs, mortgage commitments and education planning.

Similarly, income protection insurance can be designed to align with expected NHS sick pay run-on periods, with deferred periods structured so that cover begins only once NHS benefits cease. This can improve cost efficiency while continuing to protect income.

The importance of timing

One of the most critical planning considerations isn’t just what is replaced, but when it’s replaced.

Delaying pension contributions or protection planning doesn’t simply pause progress. It reduces the number of years available for compounding, and it can increase the monthly cost required to reach the same target outcome.

Crucially, while contribution levels can often be increased later, the lost growth potential from earlier years cannot be recovered. Time is, therefore, one of the most valuable inputs in any long-term plan.

It also creates a protection gap during the early phase of private practice, when financial stability is often most sensitive to disruption.

From a planning perspective, the goal should be straightforward. Ensure that the transition from NHS to private practice is matched by an immediate and structured transition in personal financial arrangements.

A structured approach to transition

Moving from NHS to private dentistry is a significant professional milestone. It’s also a shift in responsibility as much as it is a shift in income. Decisions around pensions, protection and long-term planning move from being largely embedded within employment structures to being actively managed by the individual.

A structured approach typically considers:

• Pension continuity from day one of private practice
• Replacement of spouse and dependants’ pensions
• Rebuilding death in service protection via life cover
• Reviewing ill health and long-term protection needs
• Aligning income protection with existing sick pay gaps.

The aim is not to replicate the NHS scheme exactly, but to ensure that no critical protection is unintentionally left behind.

Final thoughts

The shift from NHS to private practice is often framed around opportunity, and rightly so. But the financial implications extend beyond practice income and into long-term personal security.

As specialist financial advisers at Wesleyan Financial Services regularly highlight, the key risk is not the transition itself, but the pause that sometimes follows it.

Because when it comes to pensions and protection, time is not neutral. It’s a contributing factor in its own right.

To book a conversation with a dental specialist financial adviser from Wesleyan Financial Services, visit wesleyan.co.uk/dental or call 0808 149 9416.

Please note: charges may apply. You will not be charged until you have agreed to the services you require and the associated costs. Learn more at www.wesleyan.co.uk/charges.

This article is sponsored by Wesleyan Financial Services.

From AI-assisted paediatric dentistry to tackling the clinical record-keeping burden, this week’s updates highlight how technology, workforce investment and changing models of care are reshaping dentistry across the UK.

Dental Protection and the British Dental Association (BDA) have welcomed NHS England’s new standard operating procedures (SOPs) for clinical record keeping, describing them as a step towards a more proportionate and efficient approach to documentation.

Published on 3 August 2026, the guidance aims to reduce repetitive recording by allowing clinicians to reference agreed procedures rather than documenting routine treatment steps in full at every appointment. This could make appointment-specific information easier to identify while reducing the administrative burden on dental teams.

Dental Protection’s Raj Rattan said the guidance could help dentistry move away from ‘defensive documentation’ towards records that are clear, accurate and focused on clinical judgement and patient care.

BDA Indemnity’s head, Len D’Cruz, said dentists frequently struggle to complete contemporaneous records while working against the clock. He warned that pre-populated templates can cause problems if they fail to reflect what actually happened, adding that ‘copious notes do not necessarily mean more accurate notes’.

NHS England has published four example SOPs covering extractions, root canal treatment, crowns and onlays, and anterior composite restorations. The protocols are not intended to standardise clinical practice or restrict clinical judgement, with practices encouraged to develop procedures suited to their own workflows.

Denplan appoints new managing director to lead next phase of growth and innovation

Denplan, part of Simplyhealth, has appointed Nick Tait as managing director to lead its next phase of growth and innovation.

Tait said he was excited to return to the dental sector, adding that his wife is a dental hygienist and therapist and that dentistry has ‘long had a connection’ to his life.

Smile Together expands NHS dental access across the south west

Smile Together Community Interest Company (CIC) has expanded NHS dental provision across the south west of England with the opening of a new Dental Access Centre in Gloucester, while continuing investment in services across Cornwall.

The Quayside Dental Centre opened on 1 July 2026 following a partnership with NHS Gloucestershire Integrated Care Board and Gloucestershire County Council. The centre provides urgent NHS dental care and stabilisation services, with daytime, evening and limited weekend appointments accessed through NHS 111 or directly.

The seven-room facility is also an approved NHS Dental Foundation Training Practice, supporting newly qualified dentists and contributing to the future NHS dental workforce.

The Gloucester centre marks Smile Together’s first expansion beyond Cornwall and the Isles of Scilly, where it has continued to strengthen access. The organisation opened a new practice in Falmouth in January 2026 and another in Camborne in July, improving access to NHS care and urgent treatment.

Chief executive Jasem Greval said the Gloucester opening was an ‘exciting milestone’, adding that the organisation aims to share its community-focused approach while continuing to strengthen services across Cornwall and the Isles of Scilly.

Hello Pearl launches AI tool to tackle paediatric dental anxiety

Hello Pearl has introduced Second Opinion for Kids, an AI-assisted dental diagnostic tool designed to support communication, reduce anxiety and encourage earlier intervention among young patients.

The paediatric-focused platform analyses dental radiographs in real time to identify findings associated with dental pathology, including early carious lesions. It builds on Hello Pearl’s existing AI diagnostic technology, with child-friendly visual overlays featuring animated ‘Sugar Bug’ characters to help clinicians explain findings to children and their parents or carers.

The company said the technology aims to address key challenges in paediatric dentistry, including communicating clinical findings to young patients and building trust and cooperation during examinations and treatment planning.

Second Opinion for Kids can support clinicians in identifying and monitoring developing pathology in children from as young as four, potentially enabling earlier preventive intervention and minimally invasive treatment.

Ophir Tanz, CEO of Hello Pearl, said positive dental experiences early in life can influence attitudes towards oral healthcare, adding that the technology supports both the clinical and behavioural aspects of paediatric dentistry.

Dr Kunal Patel, founder of Love Teeth Kids in Surrey, said the visual tool helps children understand the earliest signs of dental disease, while giving parents a clearer understanding of clinical findings. He added that this shared understanding can improve engagement, reduce anxiety and encourage positive oral health behaviours.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

For Kelly, being a mom is everything. So, when she broke her wrist, she went to the OSMS Walk-In Clinic for quick and direct access to an orthopedic specialist, giving her the care she needed to confidently return to the role she loves most.

While Kelly was playing in the driveway with her children, she decided to put on her rollerblades while her boys rode around on their scooters and her two-year-old napped. At the end of her driveway, Kelly ended up hitting a bump and fell. The moment she hit the ground, she heard a crack and immediately knew in the back of her mind that something wasn’t right.

Kelly called her parents and when they arrive, her dad told her to get in the truck. While they were driving, Kelly asked her father where he was taking her – she assumed they were going to the ER – when her dad responded, “No, we’re going to go to the walk-in clinic at OSMS. You can probably get in much quicker than visiting in the ER waiting room for however many hours.”

Kelly go x-rays taken and she was seen by an OSMS orthopedic physician, they confirmed what Kelly feared. Kelly had fractured her wrist and the best path to recovery was going to be surgery.

Kelly wanted the path of whatever was going to happen the fastest. It wasn’t an ideal situation, but after being walked through the timeline of events, Kelly understood that the recovery option for surgery was much quicker than possibly casting it and seeing how long that was going to be. Kelly was comfortable with the plan, which was set the same day she walked in – on a Wednesday – and had surgery that following evening.

“I feel like I couldn’t really do hardly anything ’cause it was of course on my right hand and I’m right-handed,” Kelly explained. “I couldn’t cook, I couldn’t fold laundry like normally. Everything just took so much longer. Just normal things or just playing with my kids, strapping them into their car seat, just doing the day-to-day things.”

Kelly explained that her OSMS physician communicated with her that it would take approximately six weeks for the bone to heal, but not necessarily for her wrist to be fully recovered with full mobility. It would likely take the full year to heal.

So, when Kelly felt like there was nothing that she couldn’t do anymore than she could do before her injury, five weeks after surgery, she was pleasantly surprised. Her wrist healed much quicker than even anticipated.

Kelly described that she is back to “doing all the mom things laundry, cooking, cleaning, taking care of her kids, getting her two-year-old out of her crib, lifting her kids, and playing soccer and football.

“I 100% would recommend OSMS to anyone,” Kelly stated. “I would 100% take them to OSMS, especially just the fact that they have the walk-in clinic that you can be seen quickly. I feel like they care about you as a person, they care about your goals and just getting you back to what you want to be doing.”

Thanks to OSMS, Kelly’s back!

The post Kelly’s I’m Back Story: Broken Wrist appeared first on Orthopedic Sports Medicine Specialists (OSMS).

The post Pharma Friday – August 14, 2026 appeared first on Endocrine News.

Rana Al-Falaki explains how changing from suppression to management of stress could transform your performance, your practice, and your life.

Ask any dental clinician how they manage stress, and most will give you some version of the same answer: ‘I just get on with it.’ It is, in many ways, the default setting of the profession. We are trained to perform under pressure, to hold composure in the surgery whatever is happening internally, and to keep moving regardless of how the day feels. In dentistry, pushing through is not just accepted – it is quietly admired.

But here is what that stoicism is costing you. And it is more than you might think.

Dentistry consistently ranks among the most stressful professions in the UK. Figures from the British Dental Association suggest that stress-related issues affect up to three quarters of the profession. Burnout has become a quiet epidemic sitting at the heart of dentistry, yet the dominant cultural response remains the same: keep going, and do not show it.

The question worth exploring is not whether dentistry is stressful – it clearly is – but whether the way most of us have been taught to think about stress is actually making things worse. Because the latest evidence suggests it might be.

‘Stress is part of the job – you just have to push through’

When I first met Dr HC, he was, by every external measure, doing exceptionally well. A high-performing associate in a busy mixed practice, he was technically accomplished, reliable, and popular with his patients. His principal was happy. His diary was full. There was nothing obviously wrong.

Spend any time with Dr HC, however, and a different picture emerged. He described his working days as being on speed – moving from patient to patient with barely a pause, eating at the desk, answering messages between appointments, always just ahead of the next task because falling behind was not an option. The output was impressive. The cost was invisible. Until it was not.

The early signs were subtle. He forgot a patient’s name mid-consultation – someone he had been treating for three years. He missed a follow-up call he had promised. Then, he snapped at his dental nurse over something trivial and felt awful about it for the rest of the day. At home, he was physically present but mentally still in the surgery, running through the day’s cases while his family tried to talk to him.

These are the hallmark signs of early burnout, and they rarely announce themselves dramatically. Burnout tends to arrive quietly: as heightened irritability, difficulty concentrating, a growing sense of detachment from patients, disrupted sleep despite exhaustion, and a creeping feeling that however much you do, it is never quite enough. The most troubling aspect is that the people most at risk are frequently also the most productive,  right up until the point they are not.

When we explored what was underpinning all of this for Dr HC, one belief came through clearly: ‘Dentistry is stressful; it always has been and always will be. You just have to get on with it.’

It is a belief born of training, culture, and professional pride. It feels rational. Stoic, even. But it contains a fundamental misunderstanding about the nature of stress, and is quietly doing enormous damage.

Why pushing through is not resilience – it is suppression

Stress is a biological response to a real or perceived threat. When a stressor hits, a difficult patient, a clinical complication, a General Dental Council concern, a staffing crisis, the body responds predictably: cortisol and adrenaline flood the system, heart rate increases, breathing sharpens, awareness heightens. This is not the enemy. This is your biology doing precisely what it was designed to do: preparing you to meet a challenge with focus and energy.

The problem is not stress – it is what happens when stress becomes chronic. When pressure is relentless and there is no recovery, the very same hormones that help in a short burst begin to erode performance over time. Constantly elevated cortisol impairs the ability to focus, make decisions, retain information, and communicate clearly. People become irritable, fatigued, and emotionally flat, and increasingly vulnerable to conditions including heart disease, high blood pressure, and compromised immunity.

Pushing through, without ever processing or releasing the stress, is not resilience. It is suppression. This suppression has a cost that accumulates invisibly – until the moment it does not.

The truth: your mindset about stress matters as much as the stress itself

Here is where the science becomes genuinely fascinating, and genuinely useful.

If you think of stress as a form of energy, and physics tells us that energy cannot be created or destroyed, only transformed, then the question is not how to eliminate it, but how to work with it. The same stress response that feels overwhelming when you are fighting it can become a source of focus and drive when you understand what it actually is.

Research by Dr Alia Crum, assistant professor of psychology at Stanford University, demonstrated something that ought to be on every dental school curriculum. She found that people who viewed stress as harmful experienced the full negative cascade of chronic stress. Those who understood stress as a physiological response that could be channelled showed measurably better health, higher productivity, and greater emotional wellbeing,  even during periods of intense pressure. The difference was not the amount of stress. It was the relationship with it.

A separate study found that actively trying to avoid stress increased the long-term risk of depression, relationship breakdown, and job loss, because avoidance led people toward unhelpful coping strategies such as procrastinating, withdrawing, and imagining worst-case scenarios.

Where attention goes, energy flows: keeping your focus on eliminating stress keeps you locked in a losing battle with it.

Working with Dr HC: from pushing through to working with

We introduced Dr HC to three mindset shifts:

1. Viewing the body’s stress response as helpful rather than debilitating
2. Recognising your own capacity to grow through difficulty
3. Understanding that stress is a universal human experience, not evidence that you are uniquely failing.

His initial response was familiar. He did not see himself as someone struggling with stress. He was someone who handled it. A pusher-through. That, we explained gently, was precisely the problem.

Through the NAIL-IT in Dentistry Titanium training programme, Dr HC started to shift. The first shift was awareness: becoming conscious of the internal narrative running beneath the surface of his days. Not just the workload itself, but the constant accompanying commentary.

• ‘I cannot drop anything’
• ‘I cannot let anyone down’
• ‘I have to stay ahead.’

These were not neutral observations. They were stress amplifiers, keeping his nervous system in a state of sustained alert long after individual stressors had passed.

The second shift was reframing the stress response itself. Instead of interpreting the physical signs of pressure – the heightened alertness, the racing thoughts – as warning signals to be alarmed by, he began recognising them as his body preparing him to perform. The language changed.

‘I am overwhelmed’ became ‘I am activated’.

This shifted the emotional register entirely, and with it, the physiological response.

The third shift was accepting that stress as energy requires an outlet. Suppressing it does not make it disappear; it redirects into the body, the mood, the snapped remark, the dropped ball, the missed detail.

Within the NAIL-IT programme, Dr HC was introduced to a range of practical regulation tools: structured breathing between patients as a micro-reset, genuine lunch breaks away from the screen, and a brief end-of-day journal – not to catalogue problems, but to note what had gone well. Small practices, consistent habits. The shift in his nervous system within weeks was marked.

The true shift

Six months later, Dr HC describes his experience of work as fundamentally different. Not because the demands have reduced, the diary is just as full, but because his relationship with those demands has shifted.

His treatment conversion rate increased by more than 20%. Not through any change in clinical skill, but through the quality of his presence in the room. Patients respond powerfully to a clinician who is genuinely calm and attentive. When you are running on adrenaline, patients feel it, even when they cannot name it. When you are regulated, they feel that too. Trust builds faster. Consultations feel more natural. Treatment acceptance follows.

His clinical notes are no longer the last thing standing between him and home. With improved concentration and reduced cognitive load, he returned to completing records in real time – a habit he had long since abandoned as impractical. It turned out it was not impractical. It was simply incompatible with a mind running at perpetual high alert.

He started sleeping better, being present at the dinner table, and took up running again. He described, with some surprise, looking forward to Monday mornings for the first time in years.

Most significantly, he told us he had stopped viewing stress as a sign that something was going wrong and started viewing it as a signal that something mattered. That reframe, small in words, significant in impact, is at the heart of what the NAIL-IT leadership model teaches about stress mindset.

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Dr Kalim Sadiq explores how the VAT ruling on clear aligners could affect orthodontic practices, treatment costs and patient preferences – plus, why affordability should never outweigh clinical suitability.

I have been practising orthodontics for over 20 years and have seen many changes during that time, including the increasing use of clear aligners in preference to fixed appliances, advances in digital orthodontics and the introduction of AI with remote monitoring. Over the past decade, clear aligners have become an increasingly popular treatment option in the UK (BOS, 2023).

In a recent tribunal, it was ruled that Invisalign clear aligners do not qualify as exempt from VAT as dental prostheses and are subject to the standard rate.

Alongside rising laboratory costs, increasing dental material costs and higher staffing costs following increases in the national living wage, the VAT ruling is bound to create additional financial pressures for dental practices.

It is unlikely that every practice will be able to absorb these additional costs indefinitely. Some practices may absorb part of the increase, while others may need to reflect some of those costs in their treatment fees. Ultimately, this will depend on each practice’s business model and financial position. 

The financial impact of VAT on clear aligners

Recent British Orthodontic Society data shows that 77.3% of responding orthodontists now provide clear aligner therapy, while more than 70% have reported an increase in adults seeking orthodontic treatment in recent years.

While patients clearly continue to value aesthetic dental treatment, affordability is becoming an increasingly important consideration when choosing treatment options.

With direct to consumer aligners now widely available and fixed appliances generally carrying lower laboratory costs, patients may become increasingly willing to consider fixed braces where they are clinically appropriate. We believe the VAT ruling may accelerate a trend that we had already begun to observe in practice. 

Since the ruling, we have had patients asking whether it will affect the cost of treatment and whether fixed braces now represent better value. One patient asked during a consultation whether the increase would affect their overall treatment costs. Another patient undergoing aligner treatment asked whether their agreed treatment costs would change following the ruling. 

We also spoke to the mother of a patient who did not qualify for NHS orthodontic treatment. She expressed concern that Invisalign may no longer be financially achievable for her son and that fixed braces may now represent the more affordable option. 

How are patient attitudes changing?

Orchard Orthodontics conducted a survey of more than 100 current patients to better understand their perceptions of orthodontic appliances and the factors influencing their treatment choices. 

Our findings demonstrate that attitudes are changing. Around 91% of respondents believed adult braces are more socially acceptable today than they were five years ago. For appliance preference, 61% selected fixed braces compared with 39% selecting clear aligners. Convenience was the most commonly cited reason for appliance choice, followed by treatment time, cost, aesthetics and discreet appearance. 

These results suggest that appearance is no longer the only factor influencing adult orthodontic treatment decisions. Affordability, convenience, clinical suitability and expected treatment outcomes are all becoming increasingly important considerations. 

Ethics before cost

However, cost should never become the determining factor when choosing orthodontic treatment. The General Dental Council requires dental professionals to put patients’ interests first and ensure that treatment decisions are based on the patient’s individual needs, taking into account their circumstances, preferences and the most appropriate clinical outcome.

Patients should be informed of all clinically appropriate treatment options available to them. A clinician’s inability to provide a particular appliance should never limit what is presented to the patient. In accordance with GDC guidance: ‘If a task, type of treatment or decision is outside your scope of practice or you do not feel that you are trained and competent to do it, you must refer the patient to an appropriately trained colleague.’ (GDC, 2013)

Fixed braces and clear aligners each have advantages depending on the clinical objectives. Fixed appliances often provide superior control for significant tooth rotations, extrusive movements, impacted teeth and complex bite correction. Clear aligners may be more appropriate where maintaining camouflage, aesthetics or patient lifestyle are priorities. We must also consider the behavioural aspect of treatment, as some patients struggle to wear removable appliances consistently, making fixed appliances a more predictable option in those cases. 

Patients should therefore receive clear information about how the VAT ruling may affect treatment costs, together with an explanation of all clinically appropriate appliance options, including fixed appliances where suitable, which tend to have lower laboratory costs and may offer a more affordable alternative for some patients. 

My advice is that patients should always speak to their orthodontist and choose the treatment that is clinically right for them, rather than simply going for the cheapest option. 

References

1. BOS Survey, available at: https://journals.sagepub.com/doi/10.1177/14653125231204889 
2. BOS Survey, available at: https://www.nature.com/articles/s41415-025-8300-8? 
3. Orchard Orthodontics, 2026
4. HM Revenue & Customs v Align Technology Switzerland GmbH [2026] UKUT 00256 (TCC), Upper Tribunal Tax and Chancery Chamber, available at: https://www.gov.uk/tax-and-chancery-tribunal-decisions/2026-ukut-00256-tcc-hm-revenue-and-customs-v-align-technology-switzerland-gmbh? 
5. Office for National Statistics (ONS), released 2 May 2025, available at: https://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/bulletins/householddisposableincomeandinequality/financialyearending2024? 
6. British Dental Association (2025), page 3. Available at: https://www.bda.org/media/vexpfw1b/ddrb-25-26-round-bda-submission.pdf? 
7. https://www.gov.uk/government/news/national-living-wage-increases-to-1271-per-hour? 
8. General Dental Council, Standards for the Dental Team, Principle 1. Available at: https://standards.gdc-uk.org/? 
9. General Dental Council, Standards for the Dental Team, Principle 6 and General Dental Council, Scope of Practice guidance. Available at: https://www.gdc-uk.org/standards-guidance/standards-and-guidance/scope-of-practice? 

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Treeline Dental Group has once again demonstrated its commitment to community spirit, teamwork and social responsibility through its BIG Community Challenge in support of Dentaid, held on 27 June 2026.

The initiative brought together colleagues from across the organisation for a demanding 12‑mile coastal walk, a challenge that perfectly reflects Treeline’s ethos of stepping up, showing up and making a meaningful difference beyond the dental clinic.

A coastal challenge with purpose

The team set off from Mablethorpe Queen’s Park, heading south along the coastline towards Anderby Creek. The route offered sweeping views, bright sunshine and, on this day, exceptionally warm weather. Despite the heat, spirits stayed high. The group paused at Anderby Creek for refreshments and food before making the return journey back to Mablethorpe, completing the full 12 miles with determination and camaraderie.

Around 20 people took part, representing every corner of Treeline Dental Group: practice managers, team leads, dental nurses, receptionists, administrators, head office colleagues and both directors, Jimmey and Nav Palahey. The turnout reflects Treeline’s culture, one where every individual, regardless of role, is encouraged to contribute to the wider community and celebrate shared achievements.

Supporting Dentaid’s mission

The challenge raised £1,000 for Dentaid, a charity Treeline has proudly supported through multiple initiatives. Dentaid’s work, delivering oral healthcare to vulnerable communities in the UK and internationally, aligns closely with Treeline’s belief that dentistry should be accessible, preventive and rooted in compassion.

Treeline’s ongoing support for charitable organisations, community events and local partnerships has become a defining feature of the group’s identity. From sponsorship activities to volunteering days and large-scale staff events, Treeline consistently demonstrates that dentistry can be a force for good far beyond the clinic doors.

A culture built on people, purpose and pride

The BIG Community Challenge is the latest example of Treeline’s growing portfolio of community-focused initiatives. With practices across the East Midlands and South Yorkshire, the group has built a reputation for investing in its people, celebrating teamwork and championing local engagement. Whether through charity walks, company away days, sponsorships or collaborative events, Treeline’s teams show up with energy, enthusiasm and a shared sense of mission.

Dr Jimmey Palahey, founder and CEO, said: ‘When our teams come together for something bigger than ourselves, it reminds us of what Treeline is about – people, purpose and making a positive impact. I’m incredibly proud of everyone who took part. Their commitment, even in the heat, shows the strength of our culture and the heart of our organisation.’

A day that captured Treeline at its best

The walk wasn’t just a fundraiser; it was a celebration of Treeline’s values in action. Colleagues encouraged one another, shared stories along the route, and enjoyed the rare chance to connect outside their usual practice environments. The challenge strengthened relationships, boosted morale and reinforced the Group’s belief that meaningful experiences build stronger teams.

Raising £1,000 for Dentaid is a fantastic achievement, but the day’s impact goes far beyond the final total. It showcased Treeline’s commitment to community wellbeing, its passion for supporting national dental charities, and its dedication to creating opportunities for staff to grow, bond and give back.

Treeline Dental Group’s BIG Community Challenge stands as another proud milestone in the organisation’s ongoing journey – one defined by teamwork, generosity and a deep-rooted belief that dentistry can change lives both inside and outside the clinic.

Discover more about Treeline Dental Care here.

This article is sponsored by Treeline Dental Care.

The post In Pursuit of Precision: New Lab Tech appeared first on Endocrine News.

Around 12,550 candidates have been accepted onto dentistry and medicine courses this A-level results day (13 August), a 28% increase since 2019.

Today’s A-level results release saw more students than ever receive top A* grades, outside of the COVID-19 pandemic when predicted grades were used.

The combined figure for students accepted into competitive dental and medical schools rose by 2.2% on the previous cohort.

Jo Saxton, UCAS chief executive, said: ‘Today’s school leavers were just starting secondary school when the pandemic interrupted their education. Given the significant disruption they faced at such a formative stage of their learning, it is wonderful to see so many young people getting a place at university or college. I’m delighted to see them backing themselves and choosing to invest in their education.’

Can dentistry be accessed through clearing?

Many students who did not achieve the grades to progress onto the courses they had applied to will now be going through the clearing process to search for a university place elsewhere.

Jo continued: ‘For those who haven’t got the grades they need, are reconsidering their plans, or haven’t applied yet but are thinking of doing so, I’d encourage them to explore the wide range of choices on offer in clearing – with over 26,000 courses available there are plenty of options.’

While it is unusual for dentistry courses to be accessed through clearing, the University of Liverpool has announced that places on its BDS are available via its clearing process. Multiple courses in related disciplines such as dental nursing and dental technology are also available for applications on the UCAS clearing site.

Dental school applications soar

In June, UCAS data revealed that applications to medicine and dentistry courses had risen by 12% since the previous year. There were 134,210 applications recorded for 2026 entry, the highest level since 2019.

International interest also increased. Applications from outside the European Union rose by 14%, from 16,660 to 18,990, while applications from the European Union excluding the UK increased from 3,460 to 3,900. Combined, international applications to medicine and dentistry reached 22,890 in 2026.

Jo said: ‘It’s fantastic to see so many UK 18-year-olds holding an offer this year, putting them in a strong position as we head into the critical summer results period.

‘It’s clear that young people remain as keen as ever to invest in their futures, and I’m delighted that UK universities and colleges are responding to that demand.’

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A conversation with Jonathan Williamson, digital workflow specialist, on the advantages of in-house model and aligner production.

As orthodontic practices and laboratories continue to embrace digital workflows, one question keeps coming up: how can we produce more in-house without adding complexity, staffing pressures, or longer working hours?

Jonathan Williamson, one of the digital workflow specialists at DB Orthodontics and DB Lab Supplies, explains why the Formlabs Form 4B is generating so much interest among orthodontists and dental technicians. Having worked closely with practices, laboratories, and our own in-house production team, Jonathan has seen first-hand how the latest generation of dental 3D printing is changing what is possible.

Jonathan, what makes the Form 4B different from other dental 3D printers?

‘The first thing people are impressed with is the speed,’ says Jonathan. ‘Printing up to 11 orthodontic models in just nine minutes is a genuine game-changer. That’s not just a nice specification for a brochure – it completely changes how practices and laboratories can work.’

Traditionally, many orthodontic teams have relied on overnight printing. Models are queued up at the end of the day and staff return the next morning hoping everything has printed successfully.

‘The Form 4B removes that mindset,’ Jonathan explains. ‘You can print during normal working hours. If you need aligner models, retainer models, or diagnostic models, you can produce them throughout the day rather than waiting until tomorrow. That has a huge impact on workflow efficiency.’

Is speed the main reason people are investing?

‘Speed gets people’s attention, but accuracy and reliability are what convince them,’ says Jonathan.

Orthodontic appliances depend on accurate models. Any variation can affect appliance fit, create additional adjustments, and ultimately impact treatment efficiency.

The Form 4B delivers exceptional precision, with 95% of surfaces within 50 microns of the CAD model and 99% within 100 microns. That’s the level of consistency orthodontic professionals need when they’re producing aligner models, retainers, indirect bonding trays, and other appliances.

Just as importantly, that accuracy is maintained across the entire build platform, allowing multiple models to be printed simultaneously without compromising quality.

What about reliability?

‘Ask anyone who has experienced failed prints. Reliability suddenly becomes your number one priority.’

The Form 4B has been designed to minimise production interruptions through intelligent monitoring systems that track resin levels, temperature, print forces, and overall build conditions throughout the printing process.

‘The reported print success rate is over 98%, which is incredibly important for busy practices and laboratories. Failed prints don’t just waste resin. They waste time, delay cases, and create frustration. Reliability is often where the real return on investment comes from.’

Is the Form 4B suitable for practices that are new to digital manufacturing?

‘Absolutely,’ says Jonathan. ‘One of the biggest misconceptions about digital workflows is that they’re difficult to learn. Formlabs has done a fantastic job of making the process incredibly intuitive.’

Most users can learn the workflow in around 15 minutes. From importing scans and preparing models through to washing, curing, and finishing, the process has been designed to be simple and repeatable.

‘You don’t need a dedicated 3D printing expert in your practice to make this work. That’s one of the reasons adoption has accelerated so quickly.’

What types of orthodontic applications are customers using it for?

According to Jonathan, the majority of interest currently centres around clear aligner production and retainer workflows, but the possibilities extend much further.

‘We regularly see customers producing clear aligner models, retainer models, indirect bonding trays, occlusal splints, diagnostic models, and surgical guides. The open material capability also gives laboratories and advanced users additional flexibility when choosing materials.’

With Open Material Mode, users can work with validated Formlabs materials as well as selected third-party options, helping future-proof their investment as workflows evolve.

DB Orthodontics uses the Form 4B internally in its on-site lab. How important is that?

‘For me, it’s probably one of the biggest advantages we offer,’ says Jonathan. ‘At DB Orthodontics and DB Lab Supplies, we don’t just sell the equipment. Our own laboratory team uses the Form 4B every day. We’re producing models, testing workflows, solving challenges, and continually learning how to get the very best from the technology.’

That practical experience means conversations go beyond specifications and sales literature.

‘When customers ask questions, we’re answering from experience. We understand how the printer fits into an orthodontic workflow because we’re doing it ourselves.’

What would you say to someone considering a move to in-house production?

Jonathan’s answer is straightforward. ‘Come and see it. We actively encourage orthodontists, dental technicians, and laboratory teams to visit us and see the Form 4B running in a real orthodontic environment. You can speak to our laboratory team, ask questions, look at printed models, and understand exactly how the workflow operates from start to finish.’

He adds: ‘The technology is impressive, but what really helps people make decisions is seeing it working in practice and discussing their specific challenges with people who genuinely understand orthodontics.’

Final thoughts

The Form 4B is more than just another dental 3D printer. With the ability to print up to 11 models in nine minutes, accuracy of 95% of surfaces within 50 microns, and a reported print success rate of over 98%, it represents a significant step forward for orthodontic manufacturing.

Perhaps most importantly, it allows practices and laboratories to bring more production in-house without increasing complexity. Faster turnaround times, reduced outsourcing, predictable results, and a workflow that fits comfortably within the working day are compelling benefits for any modern orthodontic business.

And if you’re wondering whether it could work for your practice, Jonathan’s advice is simple: visit our DB headquarters, see it in action, and talk to the people using it every day.

Ready to see the Form 4B in action?

Book a call or visit our in-house laboratory and discover how digital workflows could transform your practice.

This article is sponsored by DB Orthodontics.

Damian Whitlam explores how generative AI is making it easier for patients to pursue dental complaints and negligence claims, while creating new risks and resource pressures for practices, insurers and regulators.

Generative AI is increasingly being used by patients to bring complaints and negligence claims against dental providers. The AI model makes it easier for patients to pursue disputes because the barriers to adoption are low and the technology is simple to access and use. Put simply, it has never been easier for patients to complain.

What is generative AI?

Both patients and practices are now using generative AI to bring and respond to complaints and claims. This type of AI can create new, complex content including text and images. Large language models learn patterns, relationships and structures from large datasets and then generate new content that reflects those patterns in response to user prompts.

Generative AI is a probabilistic technology. This means it predicts the most likely response based on patterns in its training data rather than retrieving facts in the way a database does. As a result, the AI can sometimes ‘hallucinate’, generating content that is inaccurate, misleading or unsupported by reliable sources, while presenting it as though it were correct.

Dental practices and their insurers therefore need to be ready to respond as efficiently as possible to this new breed of complaints and claims which present emerging risks.

Increased complexity of dental complaints and claims

Freely available generative AI tools can be used to produce lengthy letters of complaint and letters of claim running to hundreds of pages in a matter of minutes. At Weightmans, anecdotally we have seen complaints received by our dentistry clients becoming longer, more detailed and increasingly opaque as AI uses legal jargon in allegations.

What was once a short email outlining concerns can now be difficult to unpick and understand because generative AI can confidently generate incorrect legal analysis, misstate facts and even invent case law at a speed and volume that we have not previously had to deal with.

Impact on dental practices

The knock-on effect is that responding to complaints and letters of claim requires significant additional time and resource, regardless of the merits of the case.

While documents may appear polished and persuasive, they are not always accurate. The challenge for defendants is that AI-generated documents from claimants cannot simply be dismissed because they appear implausible. Practices must carefully review patient records and consult clinicians to prepare thorough responses to often confusing allegations to tight deadlines.

Where documents created using generative AI contain legal arguments that ultimately prove to be incorrect, each allegation must still be considered and addressed. That places additional pressure on practices and insurers while also raising important questions about proportionality in litigation.

Practices face growing pressure on resources as a result of the increased use of generative AI to create documentation, but failure to spot, properly investigate and acknowledge genuine concerns at an early stage can lead to protracted and expensive legal proceedings.

The risks of generative AI for defendants

Practices may consider it quicker and cheaper to use generative AI to respond to complaints and claims, but this can be risky for defendants.

Generative AI can support the response to claims process, but it cannot replace professional judgement. Every factual assertion, legal reference and clinical opinion must still be verified.

Getting the response to a claim wrong can potentially result in criticism by the court and adverse costs consequences for dental practices.

It is therefore important to seek early legal advice to mitigate these risks. Using publicly available generative AI can also cause issues around confidentiality as the materials are likely to contain health data and some models retain and uses the information for training.

Similar issues are arising in inquests and investigations by professional regulators. Complaints to regulators using generative AI are often more complex and raise wider issues which, even if often tangential, irrelevant or sometimes not even reflective of what has actually occurred, require investigation by the regulator and a response from the registrant.

As with claims, this leads to increased cost, but also higher levels of concern on the part of the individual under investigation. The use of generative AI by registrants to formulate reflections to regulators addressing alleged misconduct is also becoming more prevalent. Different regulators are adopting different approaches to its use in that context.

What the courts are saying about generative AI

The courts are already taking steps to combat the misuse of generative AI when used in legal proceedings. Judicial guidance was released in October 2025 which encouraged the court to inquire about the use of AI chatbots, and to remind litigants that they are responsible for the material they put to the court or tribunal.

This followed a number of significant court decisions from the spring of 2025 where the court put the use of AI chatbots, by lawyers and individuals, under the microscope, outlining the sanctions that could apply if misused. And in the recent case of Cork versus Smith, three solicitors were publicly admonished by the court and referred to the Solicitors Regulatory Authority after submitting misleading material containing fabricated statutory text as a result of using generative AI.

The Crown Prosecution Service also recently apologised after court documents contained non-existent legal authorities that were likely created by generative AI. While the court accepted there was no intention to mislead, it made clear that there had been a failure to verify the accuracy of authorities before the documents were filed.

The Civil Justice Council has recently published an interim position update in relation to the consultation on the use of AI for the preparation of court documents by lawyers.

The direction of travel confirms that the Working Group will continue looking at ‘maintaining the current position for AI use in professional legal drafting [namely, that existing professional responsibility frameworks are considered largely sufficient to govern appropriate use]; introducing proportionate transparency in relation to expert evidence, and recognising the distinct and evolving challenges posed by litigants in person’.

Preparing for what’s next

For the dental sector, the question is no longer whether generative AI is impacting complaints and claim. The question is now: how can practices and insurers respond most effectively to this evolution?

Those that embrace AI responsibly and maintain robust professional and legal oversight of the use of it will be best placed to benefit from the technology while managing its risks.

As generative AI continues to remove barriers to bringing complaints and legal claims, the demands on defendants are only likely to grow. It is therefore important for dental practices and their insurers to seek early legal advice to minimise the risks and significant avoidable costs that can arise.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

The post VIDEO: Clinical Trials Suggest GLP-1s May Improve fertility in Men with Obesity appeared first on Endocrine News.

• Rethinking muscle cramp causes
• The future of ultra-marathon running shoe technology
• The latest evidence on caffeine chewing gum

Rethinking muscle cramp causes

The common belief is that muscle cramping is caused by dehydration or electrolyte depletion. However, a growing body of evidence is challenging this theory, and the latest study in this area is particularly interesting.

The researchers analysed ultra-trail runners and identified nine competitors who experienced exercise-associated muscle cramps. They found no significant differences in body mass loss, urine specific gravity, or serum sodium concentration between those who cramped and those who did not. In other words, the athletes who experienced cramping were no more dehydrated and had no greater electrolyte depletion than those who remained cramp-free.

Interestingly, the runners who cramped displayed higher creatine kinase levels after the race, suggesting they experienced greater muscle fatigue and damage. The researchers also found that competitors who regularly performed lower-limb strength training were less likely to experience cramping than those who did not.

So, while maintaining adequate hydration and electrolyte balance remains critically important for performance, this study adds to the growing evidence that muscle fatigue appears to be a much stronger explanation for exercise-associated muscle cramps than dehydration or electrolyte depletion.

The future of ultra-marathon running shoe technology

A recent and highly informative YouTube Short by Nothing But Tech provided an intriguing glimpse into where the future of running shoe design may be heading. The video highlights how Adidas is continuing to push the boundaries of the supershoe era through its experimental Prime X Evo.

The Prime X Evo contains 25% more foam than Nike’s top legal racing shoe, but that extra foam also means the shoe exceeds the maximum stack height permitted under competition regulations. As a result, it is currently banned from elite competition. Despite this, its performance has been remarkable, with South African runner Sibusiso Kubheka becoming the first person to complete 100 km in under six hours while wearing the shoes. However, because the Prime X Evo is not legal for competition, Kubheka’s record is not officially recognised.

As Nothing But Tech concludes, “Today’s banned tech often becomes tomorrow’s standard.” It will therefore be fascinating to see how the supershoe era continues to evolve and whether shoes like the Adidas Prime X Evo eventually finds its way into legal competition.

The latest evidence on caffeine chewing gum

A recent systematic review and meta-analysis has offered an updated overview of the evidence surrounding the effectiveness of caffeinated chewing gum as an ergogenic aid. The review examined 21 studies and found that caffeinated chewing gum positively impacted various aspects of performance, including maximal strength, dynamic strength, isometric strength, and countermovement jump performance. Interestingly, the researchers noted that there was no statistically significant improvement in muscular endurance based on the current evidence.

It’s important to highlight that the observed benefits tended to be small to moderate rather than drastic. The biggest advantage of caffeinated chewing gum lies not in outperforming traditional caffeine sources but in its rapid action and convenience. For instance, it can be particularly valuable when time is tight, and there’s not enough opportunity to wait the usual 45–60 minutes for the effects of caffeine capsules or coffee to kick in. Chewing caffeinated gum just 10–15 minutes prior to exercise can still offer a small but meaningful boost in performance.

If you would like to learn more about caffeine and caffeinated chewing gum, our blogs and course are well worth checking out.

• Caffeine and sports performance: Pros, cons and considerations
• Caffeine and sleep: Does a pre-match coffee impact post-match sleep quality?
• How Effective Is Caffeine In Chewing Gum?
• Caffeine (course)

From us this week:

>> New course: Micronutrients for Athletes
>> New podcast: Growth, Maturation and Athletic Development in Tennis
>> New infographic: Salivary Immunoglobulin
>> New article: Hydrotherapy

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A-level results day is this week! If you missed the grades to study dentistry at university, Dakshita Goli explains your options – from resitting to other career paths in dentistry.

Results day can feel like the end of the world when things don’t go to plan, especially when you have high expectations for yourself. Missing your offer can be overwhelming and it is natural to feel defeated, but not getting into dental school on the first try does not mean your journey is over. In fact, many students including myself have taken an alternative route into the profession. 

This article will guide you through the possible next steps to take if you’ve missed your grades – from considering gap years to exploring other pathways.

When I opened my results in August 2024, I remember feeling hopeless. I was staring at my screen trying to think of a way to tell my parents that I didn’t make it. It was a tough moment, filled with disappointment and regret, but after a lot of thinking I decided to resit my A-levels and reapply.

The year was challenging in a lot of ways. However, it allowed me to reflect, to build resilience and independence, and so much more. All qualities that are just as important for dentistry as grades on a page. 

Resitting your A levels

Retaking your A levels can feel daunting. However, it is a decision that a countless number of students have taken – myself included. Before taking the decision I looked at both the pros and cons of resitting my A levels and so now I will outline a few main ones. 

Taking a year out to resit can help develop studying techniques, solidify your knowledge and build your resilience over time. For me personally I saw resitting my A-levels as a slight advantage when it came to interviews. It allowed me to talk about how taking a gap year helped develop my determination and self discipline, both characteristics that are required as a dental professional.

Dentistry is a competitive course and universities value applicants who can show perseverance and a gap year was a great example to showcase my resilience. Speaking from experience I can confidently say that a lot of students may feel as though they are ‘falling behind’ and that it will be awkward being in a cohort with students who are younger than you.

However, you’ll be glad to hear that when you eventually make it to university nobody can actually tell if you are older. In my first week of university, not a single person noticed I was older unless I brought it up myself or they knew of me beforehand! And in reality one year is a small investment when you consider the long career ahead of you.

Regardless of whether you start dentistry at the age of 18 or 25, you will end up with the exact same qualification and the main aim is to have fun while achieving it rather than letting one year hold you back.

Dealing with FOMO

Another big issue I struggled with was coming to terms with all of my friends going to university and experiencing new things whilst I was at home revising for my UCAT, interviews etc. It can be challenging at first due to the change in routine.

Going from seeing my friends everyday to seeing them do fun things without me was hard but this feeling known as FOMO (fear of missing out) does eventually fade. Over time you will come to terms with your gap year and be more accepting of it. Personally I noticed myself coming to terms with it around interview season however this may vary person to person, but just know it will get better.

One main thing that helped me get through the FOMO was having a good support system and also looking after myself. It can be easy to get swept away in being sad but it is so important to look after yourself and indulge in self love.

During my gap year I started reading a book called Good vibes, Good life by Vex King. Long story short, this book taught me that nurturing yourself can help you achieve so much more than punishing yourself for something that didn’t go your way.

I am a strong believer in the phrase: ‘Everything happens for a reason.’ Yet for some reason when I opened my UCAS on results day I didn’t think so.

In the beginning of my gap year I beat myself up a lot about how I had disappointed not only myself but also those around me. But as time went on, I realised that maybe this was the universe giving me another chance to achieve my dreams. Instead of sitting in a pit of sadness, I should have been trying again – but this time, harder.

What are the other options?

Overall, retaking my A levels was the stepping stone I needed to get into dental school, but for others, there may be better alternatives. For example, other degrees or going straight into dental nursing. 

Overall, missing grades doesn’t define your future. With determination, alternative routes or a gap year, you can still achieve your dream career.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

This article was first published in October 2025.

Multi Unit Abutments are now available with an angle of 30° – the implant prosthetic components are also compatible with Exocad and 3Shape.

Especially when manufacturing implant restorations it is important to optimally adjust components to one another. The Zirkonzahn company, run by dental technicians and one of the world’s largest manufacturers of implant prosthetic components, conceives and manufactures all components in its production sites in South Tyrol, Italy, with a full control over the product process.

In addition to the legally prescribed warranty obligation, the company grants voluntarily up to a 30-year warranty on all implant abutments used. Also, within the current Zirkonzahn warranty regulation, it explicitly includes implants from other manufacturers used with Zirkonzahn implant abutments.

Implant prosthetic components for more than 140 implant systems

All Zirkonzahn components are available for more than 140 implant systems and are fully integrated in Zirkonzahn.Software and workflow via corresponding libraries. Exocad and 3Shape users may also download and implement Zirkonzahn components for free in their design software through a dedicated portal: the Zirkonzahn Library Download Center.

Zirkonzahn portfolio consists of a great range of products: regular titanium bases, Scanmarkers, White Scanmarkers, ScanAnalogs (laboratory analogues used as scan bodies), impression copings, laboratory analogues, Raw-Abutments, and healing caps. The product line has been recently expanded with innovations, including the new Multi Unit Abutments with an angle of 30°.

Click here to have a look at Zirkonzahn’s full range of components and read the warranty regulation!

This article is sponsored by Zirkonzahn.

Even a technically strong prosthetic, which has been manufactured to exact specifications and fits first time in the mouth, can be rejected by the patient.

This apparent disconnect between technical success and patient acceptance is not unheard of and is typically the result of several different factors. While fit, function, and occlusion are crucial, aesthetics plays a leading role in patient satisfaction, meaning that all these aspects must be optimised at each stage in the treatment journey for true success.

To minimise the risk of unnecessary adjustments or remakes, the technician and dentist must work together closely to manage each case. From assessment and treatment planning through to the try-in and final prosthetic delivery, professional collaboration and communication are key.

Unrealistic expectations

The first step in each case is adequately preparing the patient. This requires the clinician to really understand the patient’s motivations for treatment and to work with them to define their desired outcomes, which can then be communicated to the dental technician. In an age when social media drives dental expectations, there is a high risk of patients visiting the practice with unrealistic or unachievable goals (Rostamzadeh and Rahimi, 2025). Addressing these early in the treatment process will help to avoid disappointment later on.

Such a situation can often be managed with the use of smile simulations. The clinician – often working with the technician – can design the predicted final smile to present to the patient as part of the treatment planning and consent workflow. Modern technologies even use AI to provide dynamic simulations that show the patient their likely new smile in motion, as well as static photos, for improved understanding and increased patient satisfaction upon treatment conclusion (Saini et al, 2025).

Elevating communication

To consistently realise these simulated results, the same high standard of communication must extend beyond the practice. The relationship between dentist and technician most commonly breaks down due to a lack of communication. Missing written details in the lab prescription, for example, has been found to affect the quality of both fixed and removable prosthodontics (Al-AlSheikh, 2012). Missing or inadequate photographs or intraoral scans, and inaccurate shade assessments will also have a negative impact on the technician’s ability to produce high-quality work.

As such, it is important to outline exactly how much information is required from the dentist for prosthetic cases. A simple checklist can be a useful tool. Clinicians should also be advised to avoid subjective terminology when describing the product needed in favour of more technical specifications. Patient wishes or their personal story may be shared separately where it is relevant to the case. Digital technology has an important role to play once again, allowing professionals to share all necessary information in a quick, convenient, and efficient way. For more complex cases that require input from both parties to effectively plan and execute, instant digital communication aids can be useful to facilitate collaboration and discussion in real time.

Continuing the conversation

After the prescription is received by the lab, it is vital that this communication continues. The wax try-in, for instance, is an excellent opportunity to explore the prosthetic design with the patient. Rather than treating it as a final checkpoint, this milestone should be a point of conversation with the patient, perhaps with the technician present too, either in-person or digitally. The patient’s feedback at this stage provides insight into any concerns and helps both professionals to ensure that the remainder of the treatment journey goes smoothly.

To optimise this step, it is important that the wax try-in is as realistic and as close to the provisional prosthetic as possible. Patients will struggle to visualise their new smile if the try-in lacks lifelike aesthetics. This can be avoided when the technician uses a high-quality wax solution such as the Aesthetic Wax Kit from Kemdent. Designed specifically to elevate the realism of wax try-ins, this innovative product selection accurately replicates the natural gingival aesthetics for an enhanced patient experience. The kit contains four specialised wax shades to imitate a natural root emergence and lifelike characterisation of the soft tissue.

Reducing rejection

If patient expectations can be managed and optimised throughout the treatment journey, giving them a sense of control at each step, their satisfaction with the final outcome is likely to be improved. Effective communication – between dentist, technician, and patient – is crucial, and the wax try-in is an excellent opportunity to promote this three-way collaboration.

References

1. Rostamzadeh, M., Rahimi, F. Aesthetic dentistry and ethics: a systematic review of marketing practices and overtreatment in cosmetic dental procedures. BMC Med Ethics 26, 12 (2025). https://doi.org/10.1186/s12910-025-01169-6
2. Saini RS, Kaur K, Gurumurthy V, Binduhayyim RIH, Kaushik A, Kuruniyan MS, Alarcón-Sánchez MA, Heboyan A. Impact of artificial intelligence-based digital smile design on patient and clinician satisfaction and facial esthetic outcomes: A systematic review and meta-analysis. Digit Health. 2025 Oct 16;11:20552076251388392. doi: 10.1177/20552076251388392. PMID: 41122427; PMCID: PMC12536214.
3. Al-AlSheikh, Hana. (2012). Quality of communication between dentists and dental technicians for fixed and removable prosthodontics. King Saud University Journal of Dental Sciences. 3. 55–60. 10.1016/j.ksujds.2012.07.002.

For more information about the leading solutions available from Kemdent, please visit www.kemdent.co.uk or call 01793 770 256.

This article is sponsored by Kemdent.

When Eshaa Hafeez narrowly missed her dentistry offer, she began looking at other routes into the profession, eventually choosing to study dentistry in Bulgaria. Here, she reflects on the competitiveness of UK admissions, plus the benefits and challenges of studying abroad.

Studying dentistry in Bulgaria seemed like an alternative pathway into the profession. However, after moving here, I realised that this route is shared by many students because of the highly competitive nature of UK dental school admissions. 

Looking back, I can see how much this journey has benefited me, not only academically but also personally. 

When I went through the application process at 17, I already understood how competitive dentistry was. I was applying alongside students with outstanding University Clinical Aptitude Test (UCAT) scores, mostly A* grades and near-perfect personal statements. 

Like many applicants, I spent months building a strong portfolio through extracurricular activities, additional academic experiences, volunteering and dental work experience. Despite all of this, there was still no guarantee of securing a place. 

Dentistry has become one of the most competitive university courses in the UK. In 2025, there were more than 9,900 applicants competing for only 1,630 places, meaning around 84% of applicants were unsuccessful. 

On results day, I narrowly missed my dentistry offer by just two marks because of high chemistry grade boundaries. It was incredibly disappointing, but I knew one setback was not going to stop me from pursuing my ambition of becoming a dentist. 

Choosing another route 

After receiving my results, I had to look at the different pathways available. Through conversations with family, current dental students and practising dentists, I identified three main options:

• Taking a gap year and reapplying
• Studying dentistry abroad in countries such as Bulgaria, Hungary or Spain
• Completing another degree and applying for graduate-entry dentistry.

Initially, I considered taking a gap year. However, this felt uncertain. I would have had to retake chemistry, sit the UCAT again, prepare for interviews and repeat the entire application process, with no guarantee of a place. 

I also researched studying abroad in countries including Poland, Latvia and Spain. While these are all respected destinations for dental education, Bulgaria stood out to me personally for several reasons. 

It is one of the most popular destinations for UK students studying dentistry, and I already had close friends and people I knew who studied there. I felt this would make the transition to living abroad much easier and help me settle into university life. 

Another deciding factor was the emphasis on clinical experience. Bulgarian dental schools are well known for providing extensive hands-on clinical training during the later years of the course. Students in the upper years carry out a large number of clinical hours and practical procedures. This practical focus was something I valued when comparing different pathways. 

Life as a dental student in Bulgaria 

Having now completed my first year in Bulgaria, I can say that moving abroad has helped me develop as a person. Living independently in another country has significantly increased my confidence and resilience. 

One of the biggest challenges has been communicating with locals. Learning and speaking Bulgarian is difficult, particularly in shops, on transport or in the street. As a result, I have developed stronger non-verbal communication skills by relying on body language, facial expressions, gestures and visual cues. 

I believe these are essential skills for an aspiring dentist, as effective communication does not depend only on language. It also relies on empathy, patience and understanding. 

Being away from family and friends has also been difficult at times, particularly during the first few months. The course also leads to a master’s-level qualification, which means we study additional compulsory subjects compared with some UK dentistry courses. Attendance at lectures and practical sessions is also compulsory.  

Despite staying in Bulgaria, I have been fortunate to study with a diverse cohort. Around 40% of students at my university are from the UK, which creates a familiar environment while still allowing us to experience a completely different culture. Within my English-speaking dental cohort, I also have friends from the UK, Ireland, Greece, Italy and Turkey. 

Returning to practise in the UK 

Another consideration I had when studying abroad was what happens after graduation. Post-Brexit, the process of returning to practise dentistry in the UK has become more uncertain. 

As of now, dentists with recognised European Economic Area qualifications can still apply to join the General Dental Council (GDC) register through the near-automatic recognition route. However, the government’s standstill arrangements have only been extended until June 2028, and the GDC has said it does not know what arrangements will apply after that. 

There have been rumours and speculation that these arrangements could be extended, but no final decision has been announced. The GDC has also been working to increase Overseas Registration Examination capacity, although demand remains high. 

This uncertainty is something students like me have to consider carefully. Studying abroad can offer valuable academic, clinical and personal experience, but it also means thinking ahead about registration, workforce requirements and how to return to practise safely and confidently in the UK. 

What this says about UK dental education 

Having completed my first year in Bulgaria, I have realised that my experience is far from unusual. Every year, around 84% of applicants to UK dental schools are unsuccessful. This highlights how restricted access to dental education has become within the UK. 

I understand that maintaining high academic thresholds is essential to ensure patient safety. However, many students with excellent portfolios are still rejected because there are too few places available. 

For many of us, this is incredibly frustrating. Years of preparation, work experience, volunteering and commitment can end in rejection despite meeting the standard expected of future dentists. Rejection does not necessarily reflect a lack of ability or dedication. Often, it reflects the limited capacity of UK dental schools. 

Many aspiring dentists are forced to explore alternative pathways, such as studying abroad or taking multiple gap years. 

Studying dentistry abroad: alternative or opportunity?

I no longer see studying dentistry in Bulgaria as simply an alternative route into the profession. Instead, I see it as an opportunity that has allowed me to grow academically, professionally and personally. 

It has challenged me to become more independent, adaptable and resilient, while giving me valuable clinical and life experiences I may not otherwise have gained. Although my journey has been different from the one I originally imagined, it has reinforced my determination to become a dentist, regardless of where it began.  

One final message I would like to highlight to UK policymakers and dental school admissions officers is to think about the future and plan for the next generation of the dental workforce, as decisions that are made today directly affect us and the quality of care the patients will receive. Every year, thousands of capable applicants are turned away and not because they lack the ability to become excellent dentists but simply because there are not enough places available.  

Educating the dental workforce is where the start of our journey begins and aligning it with the future of UK’s long-term healthcare is an investment that will allow us to continue to meet patients’ needs, provide optimal oral care and strengthen the profession. 

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

The post Compassionate Curiosity: Q&A with Martin Reincke, MD appeared first on Endocrine News.

Three weeks into Prime Minister Andy Burnham’s term, the government has announced that James Frith will take on responsibility for dentistry as under-secretary of state for health and social care.

A reshuffle of the Department of Health and Social Care (DHSC) saw Yvette Cooper announced as the health secretary and several ministers and under-secretaries introduced on 22 July. However, it was not clear at this point exactly who would take on the dentistry brief.

It has now been announced that James Frith, MP for Bury North, will be responsible for dentistry as well as several other specialisms including NHS data and technology, research and innovation, and men’s health.

When first elected as MP in 2017, Frith sat on the Education Select Committee and chaired the All-Party Parliamentary Group for Hospice and End of Life Care. During his next term starting in 2024, he then served on the Culture, Media and Sport Select Committee.

In March 2026, Frith became a parliamentary under-secretary of state in the Department for Science, Innovation and Technology. He was largely responsible for the government’s work to develop a digital identity system for the UK.

Does the profession support the newly-appointed dental minister?

Prominent members of the dental profession have welcomed Frith to the post, calling for him to follow through on the government’s previous pledges of large-scale dental reform.

Neil Carmichael, executive chair of the Association of Dental groups, (ADG) said: ‘We warmly welcome James Frith and look forward to working with him. Under Stephen Kinnock’s term, the ADG made considerable progress in addressing the massive workforce gap, and we now look to him to ensure the implementation of the interventions he announced. 

‘In addition, NHS contract revisions remain essential if we are to secure long‑term access for patients. Meaningful reform of the GDC must also be addressed during his tenure.

‘The ADG developed a close and constructive relationship with Stephen Kinnock, who recently emphasised how important collaboration with the ADG is to the department. As we continue this partnership to improve dental access across the UK, we are inviting James Frith to the table so we can brief him on the dentistry landscape, the challenges – and, most importantly, the solutions the ADG is presenting to address our nation’s dental deserts.’

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

Benjamin Tighe highlights the potential of dental hygienists and dental therapists to identify, prevent and co-manage systemic conditions such as diabetes and cardiovascular disease.

It is time to retire the notion that dental hygienists and therapists are the ‘cleaning professionals’ of the dental team. The evidence no longer supports such a limited view. Across a growing body of UK and international research, it is increasingly clear that these clinicians occupy a pivotal position in the identification and co-management of some of the most prevalent systemic conditions in Britain. Yet in too many practices – and in too many commissioning decisions – this potential goes unrealised.

The oral-systemic link: no longer a hypothesis

The relationship between periodontal disease and systemic illness is now one of the most consistently evidenced associations in modern medicine.

The Delivering Better Oral Health toolkit, published by the Office for Health Improvements and Disparities (OHID) and endorsed by all four UK chief dental officers, explicitly acknowledges that periodontal disease shares common risk factors with a range of chronic non-communicable diseases, including type 2 diabetes mellitus (T2DM), cardiovascular disease (CVD), and respiratory conditions (GOV.UK, 2021).

Risk factors – smoking, poor diet, obesity, and alcohol misuse – do not respect the boundary between the oral cavity and the rest of the body, and nor should clinical care pathways.

Almost half of all adults in the United Kingdom have some degree of irreversible periodontitis (Milward and Roberts, 2024). This is not merely a dental statistic – it is a public health crisis with systemic consequences.

Diabetes: a case study in what integration can achieve

The bidirectional relationship between periodontitis and T2DM is arguably the most clinically actionable of all oral-systemic associations. Uncontrolled diabetes accelerates periodontal disease progression, whilst periodontal inflammation simultaneously worsens glycaemic control – a vicious cycle with real-world consequences for millions of patients (Casanova, Hughes and Preshaw, 2014).

The evidence for intervention is compelling. A Cochrane review informing the 2022 updates to NICE guidelines NG17 and NG28 found moderate-certainty evidence from 30 randomised controlled trials that non-surgical periodontal treatment produces a clinically meaningful reduction in HbA1c compared to no active treatment (NICE, 2022). NICE’s own economic modelling confirms that this degree of glycaemic improvement is sufficient, in some patients, to delay or offset the need for additional pharmacological agents – rendering periodontal care not only clinically but economically justifiable within the NHS (NICE, 2022).

The updated NICE guidelines now explicitly recommend that adults with diabetes be informed of their elevated risk of periodontitis and advised that effective periodontal management can support improvement in blood glucose control (NICE, 2022). NHS England has since published a dedicated commissioning standard for dental care for people with diabetes, calling for the development of local care pathways that formally incorporate oral health assessment (NHS England, 2022).

There are currently an estimated 1.3 million people in the UK living with undiagnosed diabetes (Diabetes UK, 2024). Dental hygienists and therapists, who frequently see patients more regularly than their general medical practitioner, are ideally placed to identify risk factors, initiate targeted conversation, and facilitate timely onward referral.

Cardiovascular disease: the inflammatory pathway

The association between periodontitis and atherosclerotic cardiovascular disease (CVD) is supported by a robust body of evidence linking periodontal bacteraemia to systemic endothelial dysfunction, atherogenesis, and thrombogenesis (BDJ, 2025). Periodontitis is associated with an independently elevated risk of developing cardiovascular conditions, with inflammatory mediators including interleukin-6, TNF-α, and C-reactive protein propagating from a chronically infected periodontium into the systemic circulation (BDJ, 2025).

The European Federation of Periodontology (EFP) and World Heart Federation joint consensus report, cited within UK literature including the BSP’s own resources, notes that severe periodontitis is independently and significantly associated with cardiovascular disease and cardiovascular mortality (EFP, 2019). Importantly, periodontal therapy has been shown to reduce circulating inflammatory markers and improve endothelial function – suggesting the clinical value of treatment extends well beyond the oral cavity (BDJ, 2025).

The British Society of Periodontology has consistently reinforced that, whilst causality between periodontitis and CVD remains subject to ongoing investigation, this should not prevent dental professionals from taking a pragmatic approach: treating periodontal disease, addressing shared modifiable risk factors, and engaging collaboratively with medical colleagues (BSP, 2021).

Beyond diabetes and CVD: a broader mandate

The oral-systemic associations extend considerably further. The Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance on periodontal care in primary care notes emerging associations between periodontitis and adverse pregnancy outcomes, respiratory infections, chronic kidney disease, and rheumatoid arthritis (SDCEP, 2023). The Delivering Better Oral Health toolkit further acknowledges links between oral disease and metabolic syndrome, and notes that the risk factors driving periodontal disease are largely inseparable from those driving the UK’s broader burden of non-communicable disease (GOV.UK, 2021).

This is not an argument for scope creep. It is an argument for appropriate recognition of the clinical reality that dental hygienists and therapists encounter at the chairside daily.

The structural barrier: workforce, contract, and culture

Despite the strength of the evidence, dental hygienists and therapists in England remain systematically underutilised. A regional workforce survey published in BMC Health Services Research found that, despite the range of skills within their scope of practice, the majority of dental therapists in primary care spent most of their time undertaking work traditionally associated with the hygienist role, with factors including NHS contract ambiguity, financial constraints, and cultural inertia identified as key barriers (Farmer et al, 2020).

Progress has been made. The July 2022 NHS contract reforms – the first substantive changes since 2006 – sought to better incentivise skill-mix approaches and removed administrative barriers preventing dental therapists from working to their full scope of practice (NHS England, 2022). NHS England data confirm that the number of dental therapists participating in NHS care has increased significantly since 2022, with the proportion of NHS full-time equivalent therapist activity rising by 28% between March and December 2024 alone (NHS England, 2024).

The government has further committed to upskilling dental therapists and hygienists to ‘work at the top of their clinical potential’ from 2026 to 2027, and the 2026 contract reforms include funded annual appraisals for associate dentists, hygienists, and therapists delivering NHS care – a meaningful signal of professional recognition (House of Commons Library, 2025; GDC, 2026).

However, Eaton, Ramsay and colleagues, writing in the British Dental Journal, noted that urgent action remains required to address workforce recruitment and retention, and that contract reform alone will not be sufficient unless accompanied by cultural and remuneration changes that recognise the full breadth of what hygienists and therapists are trained to deliver (Eaton et al, 2023).

Making every contact count

The Delivering Better Oral Health toolkit is explicit: all clinical teams should ‘make every contact count’ and support patients in making healthier choices – not only for their oral health but for their general health (GOV.UK, 2021). This is not aspirational language. It is a government-endorsed standard of care applicable to every member of the dental team.

Dental hygienists and therapists are, in many cases, the healthcare professional a patient sees most consistently. They take medical histories, assess risk factors, monitor disease progression, and motivate behaviour change across multiple appointments and many years. They are skilled clinicians with detailed knowledge of the systemic implications of oral disease. When properly empowered – through training, direct access, appropriate commissioning, and inter-professional collaboration – they have the capacity to transform the detection and co-management of chronic disease at scale.

A call to act

The NHS faces sustained pressure from rising chronic disease prevalence, workforce shortages, and a primary care system stretched beyond its means. Dental hygienists and therapists represent an underutilised resource with a proven clinical evidence base, consistent patient contact, and a natural focus on prevention. The barriers to realising their full contribution are not clinical – they are structural, cultural, and contractual.

The evidence is there. The NICE guidance is there. The commissioning standard is there. What remains is the collective will – across dentistry, medicine, and the NHS – to put the mouth where it belongs: at the centre of systemic health care.

References

• British Dental Journal (2025) ‘The interrelationship between periodontal disease and systemic health’, British Dental Journal. Available at: https://www.nature.com/articles/s41415-025-8642-2 (Accessed: 6 July 2026).
• British Society of Periodontology and Implant Dentistry (BSP) (2021) Delivering better oral health: an evidence-based toolkit for prevention. Available at: https://www.bsperio.org.uk/assets/downloads/Delivering_better_oral_health.pdf (Accessed: 6 July 2026).
• Casanova, L., Hughes, F.J. and Preshaw, P.M. (2014) ‘Diabetes and periodontal disease: a two-way relationship’, British Dental Journal, 217(8), pp. 433–437.
• Diabetes UK (2024) Facts and stats. Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics (Accessed: 6 July 2026).
• Eaton, K.A., Ramsay, C., Foley, J. and Gallagher, J. (2023) ‘The dental workforce recruitment and retention crisis in the UK’, British Dental Journal, 234, pp. 235–240.
• European Federation of Periodontology (EFP) (2019) Consensus report on periodontitis and cardiovascular diseases. Available at: https://www.efp.org/news-events/news/consensus-report-on-periodontitis-and-cardiovascular-diseases (Accessed: 6 July 2026).
• Farmer, J., Currie, M., Lawton, S. and Cairns, J. (2020) ‘Findings from a regional workforce survey and symposium in England’, BMC Health Services Research, 20, 255.
• General Dental Council (GDC) (2026) NHS dental contract reforms: a positive step forward for our profession. Available at: https://www.gdc-uk.org/news-blogs/blog/detail/blogs/2026/01/29/nhs-contract-reforms-positive-step-for-profession (Accessed: 6 July 2026).
• GOV.UK (2021) Delivering better oral health: an evidence-based toolkit for prevention – Chapter 5: Periodontal diseases. Office for Health Improvements and Disparities. Available at: https://www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-5-periodontal-diseases (Accessed: 6 July 2026).
• House of Commons Library (2025) NHS dentistry in England, Research Briefing CBP-9597. Available at: https://commonslibrary.parliament.uk/research-briefings/cbp-9597 (Accessed: 6 July 2026).
• Milward, M.R. and Roberts, A. (2024) ‘Assessing periodontal health and the British Society of Periodontology implementation of the new classification of periodontal diseases’, Dental Update. University of Birmingham Pure Research Portal. Available at: https://pure-oai.bham.ac.uk/ws/files/90918584 (Accessed: 6 July 2026).
• National Institute for Health and Care Excellence (NICE) (2022) Periodontal treatment to improve diabetic control in adults with type 1 or type 2 diabetes: evidence review for NG17 and NG28. Available at: https://www.nice.org.uk/guidance/ng17/evidence/d-periodontal-treatment (Accessed: 6 July 2026).
• NHS England (2022) Dental contract reform: building dental teams — supporting the use of skill mix in NHS general dental practice. Available at: https://www.england.nhs.uk/primary-care/dentistry/dental-commissioning/dental-contract-reform (Accessed: 6 July 2026).
• NHS England (2024) Data analysis: impact of the Dental Recovery Plan. Available at: https://www.england.nhs.uk/long-read/data-analysis-impact-of-the-dental-recovery-plan (Accessed: 6 July 2026).
• Scottish Dental Clinical Effectiveness Programme (SDCEP) (2023) Prevention and treatment of periodontal diseases in primary care: references. Available at: https://www.periodontalcare.sdcep.org.uk/references (Accessed: 6 July 2026).

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Charl du Toit explains why he lets the technology do the talking when it comes to meeting patient expectations for comfortable, painless techniques in dentistry.

A continuous cycle exists between dental marketing and patient demand, creating a feedback loop. Social media posts featuring perfect smiles and enhanced aesthetics raise aspirations, which in turn generate more promotional content. While this ‘sells dentistry’ and shapes perception, it can present unprecedented challenges for dentists, with patients presenting in the chair seeking quick fixes and easy treatment. The onus then is on dentists to deliver on this.

As such, trust remains fundamental to quality clinical care. It is built through open, face-to-face communication and an honest exchange of information. The best approach is to ‘under promise, over deliver’, which helps align expectations about clinical results and the patient experience.

Charl du Toit would agree. He is practice principal at Newbury Smile Studio, which provides general and cosmetic dentistry in Berkshire. Having qualified in South Africa, he has been a private practitioner in England since 2001 and, like many of his contemporaries, has witnessed the shift towards aesthetic treatments and the value of a more minimally invasive approach. He has refined his approach to dental care, improving both his equipment and his communication with patients.

He says: ‘At Newbury Smile Studio, we stay current with our dentistry and learn new techniques to help meet the demands of modern society. However, we primarily concentrate on putting our patients first and ensuring they always receive the highest level of dental care.’

The impact of painless techniques

Newbury Smile Studio is a private dental practice with a special interest in helping people suffering from TMJ problems and those who are anxious. Over time, it has incorporated soft-tissue lasers, intraoral scanners, TMJ therapy, 3D digital X-rays and painless anaesthesia technology into its offerings.

Regarding the latter, a 2024 paper (Tom, 2024) suggested that: ‘Integrating painless techniques into practice can help patients struggling with dental anxiety and also help clinic owners build and grow their practice.’

Charl has seen the benefits, as have his patients.

Among the many five-star Google reviews, one patient writes: ‘It’s the most professional and friendliest dental practice I have ever used. Everyone in the team is so kind and welcoming. You couldn’t be in better hands. They have all the latest equipment and technology, which is very reassuring. They are always so accommodating when making appointments. It’s just such a nice, relaxed environment.’

Tackling dental phobia

Charl says: ‘While we are a general practice, we are also geared up to welcome patients with dental phobias. The practice offers RA and IV sedation, and we sometimes collaborate with a hypnotherapist on the premises. Using The Wand, a computer-assisted anaesthetic system, was almost a natural add-on.’

He first encountered The Wand when he bought a practice that had already invested in the digital technology, and it is now the only form of anaesthesia he uses with his patients.  

‘Initially, I believed I didn’t need it because I considered myself highly skilled at injecting. However, after attending a training course on its use, my perspective changed completely. It’s been almost 14 years now. I would like to communicate the advantages of The Wand more effectively, but I prefer to “under promise and over deliver”, so patients realise how superior The Wand is only when they experience it.’

So, has he seen an increase in case acceptance or new patient referrals due to this improved comfort?

‘For sure. Patients, amazed by the painless treatment, can’t help but share their positive experiences with friends. While the traditional dental injection often appears intimidating, The Wand seems benign by comparison. And most of the time, the fact that it offers significantly greater comfort than conventional injections is often enough to make a decisive difference. However, being able to perform single-tooth anaesthesia, where the lip does not go numb, is also a big selling point.

‘There is a technique where you can numb the upper front 10 to 12 teeth with two palatal injections. This helps a lot in aesthetic cases. The patient can still smile as the lip does not numb, but the teeth do not feel pain during the try-in of crowns or veneers.’

How do painless techniques benefit dental professionals?

In fact, the comfort benefits extend to practitioners as well.

‘It causes fewer unsettled responses for patients, but its pen-like grip is comfortable for clinicians, too. The handpiece can be shortened to improve access and visibility, and since no pressure is required, the risk of repetitive strain injury is reduced. The immediate onset of anaesthesia also saves chair time. 

‘But, in my practice, the return on investment is more about the patient returning. No pain with the injection means the patient comes back for more treatment.’

The Wand is exclusively available from Dental Sky.

Charl adds: ‘It meets the needs of a practice like mine, but I would say it is a must-have in any practice. Explaining that we use an injection system that uses pressure feedback to make it less painful and much more comfortable is half the battle won.’

And, while he recognises that high-tech dentistry and innovative dental solutions can be a game-changer for business, it is the relationships with his patients that underpin the practice’s success. The proof is in those consistent five-star Google reviews Charl and his team receive.

As one happy patient writes: ‘Charl put together a programme that has completely transformed my smile and was way better than my own expectations.’

Testament perhaps to his philosophy of under-promising and over-delivering, and an ability to deliver an experience that goes above and beyond.

References

1. https://www.sciencedirect.com/science/article/pii/S0020653924002570

This article is sponsored by Dental Sky.

Topical authority helps AI search systems recognize your website as a dependable source for a defined subject. It does not come from page volume alone. It comes from clear expertise, complete topic coverage, useful internal connections, original proof, and consistent brand signals. Without that foundation, AI may retrieve your page yet choose another source for its answer or citation.

What Is Topical Authority for AI Search?

Topical authority describes the trust and expertise a website earns across one focused subject. Each page supports the same clear area of expertise while it avoids unrelated traffic goals.

Traditional SEO often treated one keyword and one page as the main unit of work. AI search uses a wider context. Google explains that its AI search features can create several related searches through query fan out, then retrieve useful pages from its search index. That process rewards sites that cover connected needs with depth and clarity.

A pillar page defines the central subject. Cluster pages answer narrower questions. Contextual internal links show how those answers relate. Together, they create a clear path for people and search systems.

What Determines Topical Authority for AI Search?

Content breadth matters, but page count does not prove authority. A focused library needs several qualities:

• Complete coverage of the questions that matter to the audience
• Accurate answers with clear dates, sources, and expert review
• Firsthand insight, such as case data, original examples, or specialist commentary
• Logical internal links between related pages
• Consistent authors, services, credentials, and brand descriptions
• Relevant mentions from credible sites, videos, directories, and professional communities
• Strong technical access for search crawlers

The benefits of topical authority in SEO content planning start with better priorities. Rather than choose isolated articles from a keyword list, teams can map a subject, find gaps, protect pages from overlap, and direct each page toward a distinct user need.

Semantic SEO and topical authority also work together. Semantic SEO clarifies the people, services, conditions, tools, and ideas within a subject. Topical authority proves that the brand can explain those relationships with accuracy and useful depth.

Why AI Search Prioritizes Topical Authority

AI search does not simply select the page with the most repeated keywords. It retrieves sources, compares relevance, and creates a combined answer. A 2026 controlled study ran 252,000 trials across six language models. The researchers found that topical relevance and source position had the largest effect on which source earned the first citation.

A separate 2026 study of Google AI Overviews found that nearly 30% of cited domains did not appear among the first page results Google showed for the same queries. A classic page one rank may help, but it does not guarantee selection inside an AI answer.

A brand can hold strong search positions yet lose the citation when another source gives a clearer, more relevant answer. A smaller specialist can also earn visibility when its content matches the exact topic and supports the answer with stronger evidence.

Building topical authority for AI models therefore requires more than publication volume. It requires a clear relationship between the brand, the topic, the audience, and the proof behind each claim.

Steps to Build Topical Authority for AI Search

The key steps to build topical authority for content start with focus, not output.

1. Define Your Topical Authority and Differentiation

Choose the subject where your brand can offer real value. Define the audience, the problems you solve, the services or products tied to the topic, and the proof that separates you from broad publishers.

For a healthcare practice, “orthopedics” may feel too wide. “Nonsurgical knee pain care for active adults” gives the team a clearer content boundary and a stronger basis for useful examples.

2. Evaluate How AI Search Understands Your Topical Authority

Ask major AI search tools the questions your prospects ask. Note which brands appear, which sources receive citations, and how each system describes your company. Test several prompt forms because results can vary by prompt and platform.
Does the About page state your specialty clearly? Do service pages use the same terms as professional profiles? Do author pages confirm expertise?

3. Optimize Content for Topical Authority

Audit current pages before you commission new ones. Merge duplicate articles. Update old claims. Improve weak introductions with direct answers. Add useful examples, expert review details, descriptive links, and clear next steps.

Build a content map around one pillar page and its related questions. Each cluster page should answer a distinct need and link to the next logical question. This creates a practical SEO topical authority strategy rather than a loose archive of posts.

4. Publish Expert Content That Builds Topical Authority

Generic summaries add little value because AI systems can produce similar text at almost no cost. Publish material that reflects your real access and experience.

Use original surveys, case examples, expert interviews, process explanations, decision criteria, comparison tables, and lessons from actual client work. Google advises site owners to create useful material with a unique point of view instead of content that merely repeats common information.

5. Strengthen Entity Signals for Topical Authority

Keep the brand name, specialty, leadership details, service descriptions, and contact information consistent across the website and credible external profiles. Add accurate Organization, Person, Article, and Breadcrumb schema where each type fits the visible page.

Earn relevant third-party mentions through expert contributions, podcasts, research partnerships, professional associations, and strong public resources. Do not buy empty mentions. Google states that inauthentic mentions do not offer a sound path to AI visibility.

At Practice Builders, we view topical authority as a trust system, not a blog quota. A healthcare brand should connect expert knowledge, patient questions, service pages, local relevance, technical clarity, and outside credibility. That unified structure helps people find the right answer and gives AI search systems a clearer reason to cite the source.

Topical Authority Mistakes That Limit AI Visibility

• Publish one page for every keyword variation
• Enter topics that have no clear link to the brand
• Create several pages that answer the same question
• Use broad claims without proof or expert review
• Leave old dates, statistics, and service details on live pages
• Hide expertise behind generic author names
• Add internal links without a clear user purpose
• Treat a schema as a shortcut instead of a description of visible content
• Track search rank alone and ignore AI citations, brand mentions, and assisted conversions

These mistakes create noise, reduce trust, and waste content resources.

Topical Authority Conclusion for AI Search Success

Topical authority gives search systems a clear answer to three questions: What does this brand know? Why should anyone trust it, and when should an AI system cite it?

The brands that act now can replace scattered content with a focused authority system. Review your topic coverage, remove weak duplication, add real proof, connect related pages, and measure citations across AI search tools. Practice Builders can help healthcare organizations build an SEO and AI visibility plan that turns expertise into discoverability, trust, and qualified demand.

A near-infrared photoimmunotherapy technique first developed for cancer treatment has been adapted to selectively target periodontitis without a detrimental impact on the oral microbiome.

The method uses an antibody-dye compound that binds to target cells, activated by near-infrared light. In experiments, it bound to Porphyromonas gingivalis – a key pathogen that triggers periodontitis inflammation – while having no effect on human cells and harmless bacteria.

Researchers from Nagoya University have published an exploration of the potential of photoimmunotherapy for periodontitis treatment in the Journal of Translational Medicine. When tested on mice, the technique significantly reduced alveolar bone loss and improved the oral microbiome.

What benefits does photoimmunotherapy have over existing periodontitis treatments?

Existing treatments for periodontitis such as antibiotics and antimicrobial photodynamic therapy (aPDT) are not selective in the microorganisms they destroy. This means they often eliminate beneficial oral bacteria alongside harmful pathogens.

Kazuhide Sato, lecturer at Nagoya University and one of the paper’s corresponding authors, said: ‘These approaches often disrupt the entire oral microbial ecosystem and can also release lipopolysaccharide (LPS), an endotoxin that may exacerbate inflammation.

‘Results demonstrated that, unlike antibiotics or standard light therapy, this approach selectively removes the primary pathogenic species while preserving the remainder of the oral bacterial community.’

What’s next?

The researchers note that periodontitis can be caused by many different pathogens, so targeting one may not be enough. In future research, they hope to use artificial intelligence to identify other important bacteria in inflammatory processes and develop more precise treatments.

As periodontitis has been linked with systemic health problems such as diabetes, the paper’s authors also hope their research could help identify patients who are the most likely to benefit from targeted treatments.

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The post Acromegaly Mortality Rates Drop Sharply Amid Better Tools and Personalized Care appeared first on Endocrine News.

Les Jones speaks to Shiv Pabary about why funding remains the biggest obstacle to the government’s longstanding promise of NHS dental contract reform.

Although this podcast was recorded at Dentistry Show Birmingham in May, a change of Prime Minister has so far yielded no indications as to whether this new regime will honour the promises of the previous team to bring about contract reform by the end of this parliamentary term.

During his discussion with Practice Plan creative consultant Les Jones, BDA chair of the GDPC, Shiv Pabary, corrects the notion that the changes to the NHS dental contract introduced in April equated to reform. He asserts they were simply minimal changes introduced within the same financial envelope. As Shiv reminds us, the elephant in the room regarding reform, which he describes as the ‘F-word’ (funding), has yet to be addressed.

The British Dental Association (BDA) estimates £1.5bn is all that’s needed to bring about the changes needed to improve the state of NHS dental services. As Shiv points out, the U-turns on the two-child benefit cap and the winter fuel allowance represented more than £3bn, which leaves him wondering whether neglecting NHS dentistry is about political choice rather than affordability.

Time is running short for contract reform

Contract reform requires honesty and ownership from the government. The profession can make suggestions as to how the provision of NHS dental care can be delivered but ultimately, solutions need to be owned by the government. Whether that be a core service limited by the treatments available or people treated, the choice is not one for the profession to make, but the administration.  

As someone who teaches final year dental students, Shiv is ideally placed to tap into the career aspirations of young dentists. Disappointingly for him, very few of them see themselves providing NHS care in five years’ time. Without an attractive NHS dental contract, the drift away from the NHS will continue unabated and the service will wither on the vine. Time is running short to save it.

Practice Plan has been welcoming practices into the family since 1995, helping them to grow profitable businesses through the introduction of practice-branded membership plans. If you’re looking for a provider to be by your side through a safe move from NHS to private then, with over 300 years’ dental experience in our field team, you’re in safe hands with Practice Plan… Be Practice Plan and get in touch.

Call 01691 684165 or visit www.practiceplan.co.uk/be-practice-plan/.

This article is sponsored by Practice Plan.

This week in dentistry, research found that the ‘polar bear’ personality type is most common in dentistry, more than 500,000 tubes of toothpaste were donated to families and Cornwall’s first Dentistry Summit highlighted ways to improve access to NHS dentistry across Cornwall and the Isles of Scilly.

Dentists and tigers and bears, oh my!

Dentistry tends to attract people with highly precise, practical and methodical personalities, according to new research from business growth consultancy Growth Animals.

Using an animal-based personality framework inspired by the work of Carl Jung and developed with personality type author David Hodgson, the consultancy found that dental professionals most commonly display characteristics associated with its ‘polar bear’ and ‘tiger’ personality types.

Founder Chris Thornhill said dentistry attracts people who remain calm under pressure and are motivated by producing high-quality work rather than seeking recognition.

According to the research, ‘polar bears’, who make up around 12% of the UK population, are characterised by high standards, attention to detail and a methodical approach. These traits are well suited to dentistry, where precision and consistency are essential, although the report suggests they can become resistant to change if they do not embrace continuing professional development.

Meanwhile, ‘tigers’, representing around 6% of the population, are described as practical, adaptable and confident. Growth Animals says these qualities make them particularly well suited to roles such as dental hygienists and dental nurses, where quick thinking and hands-on problem solving are important. However, their tendency towards impatience can be a challenge during procedures requiring careful, methodical work.

More than 500,000 tubes of toothpaste donated to vulnerable families

Colgate-Palmolive has partnered with charity The Multibank to donate more than 500,000 tubes of toothpaste and other personal care products to families across the UK.

The ‘Summer of Smiles’ initiative comes as tooth decay remains the leading cause of hospital admissions among children aged five to nine years. Around 30% of five-year-olds in England have experienced tooth decay, while children living in the country’s most deprived areas are 2.5 times more likely to be affected.

Founded by former Prime Minister Gordon Brown, The Multibank redistributes surplus products donated by businesses to families experiencing material poverty. The charity, backed by ambassadors including David Tennant and Peter Capaldi, operates hubs in Fife, Swansea, Middlesbrough, Wigan, Birmingham and London, where the donated products are already being distributed.

Smile Together highlights NHS dentistry solutions at Cornwall summit

Smile Together has welcomed the outcomes of Cornwall’s first Dentistry Summit, where its chief executive joined healthcare leaders to discuss practical ways to improve access to NHS dentistry across Cornwall and the Isles of Scilly.

Held at Lys Kernow and organised by Cornwall Council, the summit brought together representatives from healthcare, local government and the dental profession to explore the challenges facing NHS dental services and identify collaborative solutions to improve patient access.

Speaking on an expert panel, Smile Together CEO Jasem Greval outlined how the employee-owned community interest company is expanding access to NHS dentistry through community-based services, outreach initiatives and preventive programmes. The organisation also showcased its work through an exhibition highlighting its mobile dental unit, school oral health programmes and partnerships with local organisations.

Partnership aims to improve oral health for 115,000 children in Tanzania

An international partnership involving GC Europe, Bridge2Aid, Colgate-Palmolive Tanzania and Tanzanian health organisation THEDI is set to improve oral health education for more than 115,000 schoolchildren in the Sengerema District of Tanzania.

The initiative, delivered in collaboration with local government authorities, will also reach thousands of families through oral health messages shared in schools, healthcare facilities and local communities.

Sengerema District has a population of around 500,000 but is served by just two dentists and three dental therapists, making prevention and community education a key focus.

Representatives from 60 schools and 44 villages took part, while GC Europe distributed toothbrushes donated by several European dental suppliers to participating schools and communities.

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Nigel Jones offers his views on the recent announcement of 50 new dental school places to be divided between the Universities of East Anglia and Portsmouth and whether they will solve the workforce issue in UK dentistry.

Despite having more than 40,000 on the register, we do not have enough dentists in the UK. This can be attributed to the fact that dentists, in many cases, are working fewer hours on average resulting in the full-time (or whole time) equivalent reducing. Although it may settle down, there appear to be no signs of a prospect of meaningful change to this trend. So, it seems that the part-time working dentist is here to stay.

This is probably due in part to the demographics of the profession. Dentistry is a supremely flexible profession. This flexibility appeals to people who want to combine a career with caring for a family which may account, in part for the reason that there are more female than male dentists on the register, currently roughly 53% versus 47%.

As well as this, the pandemic prompted everyone, both men and women, to consider stepping back and working part time to avoid burnout. This has also contributed to a reduction in clinical hours. Being able to work part time is likely to ensure that the appeal of dentistry as a profession will endure but will we get to the point where we have enough dentists?

The productivity challenge

As well as the part-time working challenge, dentistry also has an issue around productivity. Dentists who are retiring or approaching retirement work at a much faster pace than those entering the system at the moment. It’s tempting to say: ‘It was ever thus.’ To a certain extent that statement would be valid, as after 30 or 40 years of practise, clinicians would have honed their skills so they would be more efficient and therefore more productive.

However, my sense is that those graduating from dental schools now are doing so with less confidence and clinical experience than their predecessors. The result is they’re already slower. When we add into the mix the fear of litigation, complaints and the General Dental Council, these encourage clinicians to work more slowly, take fewer risks, and spend valuable time writing excessive patient notes to protect themselves from anything that might come down the line at a later date. All of which hamper productivity.

In summary, there is a huge issue with workforce as there are too few dentists working too few hours while being less productive when they are working. The fee per item system in place 30 years ago meant the same number of dentists delivered much more patient care than would be provided by the same number of dentists now who are paid in UDAs.

These are issues that most certainly need to be solved.

Supply and demand

However, ironically, they put the profession in a position of strength because of the laws of supply and demand. The supply of dental services is restricted and the demand, partly because of cosmetic dentistry and partly because of general dentistry, has increased.

This, to a certain extent, can be pegged to the rising popularity of cosmetic procedures and the desire for straighter whiter teeth. However, within general dentistry, demand has also increased thanks to an aging population many of whom have been able to retain their natural dentition which needs maintaining.

This increased demand coupled with reduced clinical hours and productivity put the profession in a strong position. Consequently, some dentists who may previously have been hesitant to leave the NHS for private dentistry for fear of failure, now feel confident that such a move could work for them.

Most dentists who choose to make the move away from NHS dentistry do so, not out of a desire to make more money, but rather to be able to work at a slower pace and see fewer patients for longer appointments for the same money. However, every dentist who chooses to leave the NHS to see fewer patients, creates the need for another dentist to handle the 50% of patients no longer being seen by the newly private dentist. So, there is no sign of the shortage easing.

A drop in the ocean

There have been calls, often from MPs in areas known as dental deserts, for new dental schools. Their suggestion is that dental students will stay and practise in the area once they have qualified. However, they seem to overlook the fact that dental deserts are characterised by being areas with little or no access to NHS dental services usually with high levels of deprivation.

If there is a shortage of NHS contract holders in these areas, what would be the employment prospects for the new graduates from their proposed dental schools? Also, how likely is it that a recent graduate wanting to make the most of their career would want to remain in an area of high deprivation?

The dental school suggestion to me feels like a token gesture which would take a number of years to bear fruit. Not only because of the length of time it takes for students to complete a dental degree, but also because of the lengthy processes involved in obtaining the relevant permissions and so on to be able to set up new dental schools to train the additional students.

Are there enough teachers to support new dental school places?

The recent announcement of the additional 25 places at the University of East Anglia and Portsmouth dental schools also brings into question whether there are sufficient educators able to deal with these increases. Perhaps because the increase is slight, it may be manageable. However, my sense is dental schools are already struggling to stay on top of the workload they have already and that retaining educators is a difficult task. To begin increasing the workload at a time when dental schools are already struggling to keep up could be problematic.

The British Dental Association (BDA) estimates that the unmet need for dental services currently stands at 14 million adults. Adding 50 new places a year to a register that is between 40,000 and 50,000 strong is a drop in the ocean which is why I have little faith it will make a material difference. The only possible way forward is meaningful reform of the contract that comes with additional funding. As the new Prime Minister settles in, it remains to be seen whether it will make good on its promise to bring about dental contract reform within the life of this parliament.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends. 

Antibiotic Stewardship: An Untapped Resilience Solution

1. Emily S Spivak , Jessica Tobin , Adam L Hersh , Alexis P Lee. Greenhouse gas emissions due to unnecessary antibiotic prescriptions, Antimicrob Steward Healthc Epidemiol  2024 Sep 4;4(1):e114.  doi: 10.1017/ash.2024.354/
2. Antibiotics and adverse quality of life: https://jamanetwork.com/journals/jama/fullarticle/2666503#google_vignette
3. Image: KFF Health Tracking Poll (May 5-25, 2025).

About the Author: Dr. Preeti Jaggi is Professor of Pediatrics and Infectious Diseases at Emory University School of Medicine, and Medical Director of the Antimicrobial Stewardship Program at Children’s Healthcare of Atlanta, Georgia. Her email is preeti.jaggi@emory.edu

Smarter Purchasing Builds Stronger Practices

Judy Holm

Healthcare organizations make hundreds of purchasing decisions every year. From medical supplies and exam room equipment to cleaning products, office electronics, lighting, and pharmaceuticals, every purchase impacts operating costs, patient care, staff well-being, and the environmental footprint of the practice.

Too often, procurement is viewed simply as buying products at the lowest possible price. Today, leading organizations recognize that procurement is a strategic management function that helps build stronger, more resilient organizations.

For healthcare professionals, practice managers, and clinic administrators, smarter purchasing begins by looking beyond the initial purchase price and considering the total value of a product throughout its lifecycle. An inexpensive printer may require costly repairs later. Outdated lighting systems consume more electricity. Low-quality disposable products generate additional waste. In contrast, durable equipment, energy-efficient technologies, and thoughtfully selected products often reduce operating expenses over time while improving the practice environment.

How Strategic Procurement Improves Financial Performance, Resilience, and Environmental Sustainability
This broader perspective also strengthens organizational resilience. Healthcare practices depend on reliable suppliers, efficient equipment, healthy indoor environments, and stable operating costs to continue providing high-quality care during periods of disruption. Procurement decisions made today influence how well a clinic responds to tomorrow’s challenges, whether those challenges involve supply shortages, rising utility costs, extreme weather, or changing patient expectations.

Many purchasing decisions also support environmental sustainability without increasing operating costs. Selecting ENERGY STAR® equipment, reducing unnecessary packaging, choosing reusable products where clinically appropriate, purchasing lower-toxicity cleaning products, and evaluating supplier sustainability commitments can reduce waste, lower energy consumption, and create healthier environments for patients and staff.
Strategic procurement also shapes how a healthcare organization is perceived by the people it serves. The staff and patients notice the waste in healthcare settings and want us to do better. Practices that incorporate sustainability into everyday purchasing decisions often strengthen their reputation while creating healthier indoor environments and reducing unnecessary waste.

An Opportunity To Strengthen Your Practice
The goal is not perfection. It is making better-informed decisions one purchase at a time. My Green Doctor helps practices identify these opportunities through friendly one-on-one coaching, proven tools, and step-by-step guidance. Rather than asking busy healthcare teams to become procurement specialists, the program integrates smarter purchasing into everyday practice management. Participating clinics are shown opportunities to reduce operating costs, improve efficiency, strengthen resilience, and advance environmental sustainability simultaneously.

Free Patient Education Resource

My Green Doctor offers a free library of printable waiting room brochures, including its popular Green Cleaning brochure, to help inform patients on healthy, sustainable living. Use and share the QR code to read the brochures, or download these for your practice at: https://mygreendoctor.org/resources/waiting-room-brochures/ .

References    

1.McKinsey & Company. Procurement’s Sustainable Revolution. https://www.mckinsey.com/capabilities/operations/our-insights/procurements-sustainable-revolution
2. McKinsey & Company. A New Era for Procurement—Value Creation Across the Supply Chain. https://www.mckinsey.com/capabilities/operations/our-insights/a-new-era-for-procurement-value-creation-across-the-supply-chain
3. Harvard Business Review (Sponsored). Optimizing Business Outcomes by Investing in Sustainable Supply Chains and Procurement. https://hbr.org/sponsored/2023/10/optimizing-business-outcomes-by-investing-in-sustainable-supply-chains-and-procurement

Wildfire Preparedness Is Healthcare Preparedness

Wildfires are no longer just a concern for communities near forests or grasslands. Today, wildfire smoke has become a widespread public health issue that can affect patients hundreds or even thousands of miles from an active fire. For primary care practices and for certain specialties such as geriatrics, pulmonary, and cardiology, preparing for wildfire season is no longer optional. It is an important part of being a resilient practice.

Smoke from wildfires contains fine particulate matter (PM2.5) that can penetrate deep into the lungs and enter the bloodstream. Exposure has been linked to worsening asthma, chronic obstructive pulmonary disease (COPD), cardiovascular disease, diabetes, pregnancy complications, and other chronic medical conditions. A recent systematic review also found that wildfire smoke exposure is associated with increased respiratory hospitalizations and higher mortality.

The challenge for healthcare professionals is that patients often underestimate their risk. Many assume that if they cannot see flames nearby, they are safe. However, research from the record-breaking 2023 Canadian wildfires demonstrated that smoke traveled across North America and even reached Europe, exposing hundreds of millions of people to unhealthy air quality. The health impacts of wildfire smoke are not limited by geography.

Fortunately, preparedness does not require expensive new programs. It begins with practical planning and proactive patient education.

As wildfire season approaches, healthcare teams can use their staff meeting to review asthma and COPD action plans. Part of your plans should be for physicians and nurses to encourage patients to follow every day the local Air Quality Index (AQI) and to provide them the free link: https://www.airnow.gov/aqi/aqi-basics/. Clinics can recommend that patients remain indoors during smoke events, recommend high-quality indoor air filtration in the home, and check that vulnerable patients have adequate supplies of rescue inhalers before poor air quality develops. These conversations are particularly valuable for children, older adults, pregnant women, and patients living with chronic respiratory or cardiovascular disease.

Healthcare organizations should also consider their own operational resilience. Wildfire smoke events can disrupt normal clinic operations, making preparedness essential for maintaining continuity of care. Reviewing HVAC maintenance schedules, evaluating indoor air filtration systems, expanding telehealth capabilities, developing communication plans for high-risk patients, and educating staff about smoke-related health risks can help practices continue serving their communities during prolonged smoke events.
These actions represent more than emergency planning. They are part of building healthcare resilience. A resilient practice anticipates changing conditions, prepares in advance, and continues providing safe, high-quality care even during environmental challenges. As wildfire seasons become longer and more intense, healthcare organizations that prepare today will be better positioned to protect both patients and staff tomorrow.

Free Patient Education Resources

My Green Doctor offers a library of free state-of-the-art waiting room brochures for your patients covering a dozen topics, including our brochure, “Air pollution and Wildfires in a Changing Climate: Protecting Your Family.”  These can be read on a computer or smart phone using a URL link or by the QR code that you can give to patients and families. Most are provided in English, Spanish, and Chinese. You are welcome to print these yourself or purchase them economically by emailing My Green Doctor. For Entire Practice Green members, new orders come with a complemenary six-brochure display stand for the waiting room. This is about protecting your patients and their families!

Waiting Room Brochures:
https://mygreendoctor.org/resources/waiting-room-brochures/

References

1. Gould CF, Heft-Neal S, Johnson M, et al. Health Effects of Wildfire Smoke Exposure: A Systematic Review and Meta-Analysis. Annual Review of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC12183787/
2. Zhang Q, Wang Y, Xiao Q, et al. Long-range PM2.5 Pollution and Health Impacts from the 2023 Canadian Wildfires. Nature. 2025. https://doi.org/10.1038/s41586-025-09482-1About the Author:  Judy Holm is Marketing and Communications Consultant for My Green Doctor. She specializes  in sustainability, resilience, circularity, healthcare, and design. She is an MIT-certified Climate Change Consultant.

The post Green Practice News – August 2026 first appeared on My Green Doctor.

Introduction: The Question Most Physicians Ask Backward

Physicians planning a practice almost always frame the entity question the same way: LLC or S-Corp? It is the framing that general small-business advice supplies, and it is the framing most online comparison articles adopt.

For a medical practice, it is the wrong starting point, and it skips the constraint that actually governs the answer.

In most states, a physician cannot operate a clinical practice as a standard LLC at all. State law requires a professional entity: a professional corporation or a professional limited liability company, owned by licensed physicians. The reason is the corporate practice of medicine doctrine, and it removes several of the options that a generic comparison would present as live choices.

The second problem with the usual framing is that it compares things that are not comparable. An LLC is a legal entity created under state law. An S-Corporation is a federal tax election. They are not alternatives to one another. A PLLC can elect S-Corp taxation. A PC can elect S-Corp taxation. Asking whether to be an LLC or an S-Corp is a little like asking whether to buy a sedan or an automatic transmission.

Framed correctly, there are two decisions. First, which legal entity does your state permit you to use for the practice of medicine? Second, how should that entity be taxed? The first is largely determined by state law and is often narrower than physicians expect. The second is where genuine planning happens, and where the money is.

This guide works through both, along with what liability protection actually does and does not cover, the 2026 tax landscape following the One Big Beautiful Bill Act, governance considerations for multi-physician practices, and how the structure chosen today affects a sale or private equity transaction years from now.

The Corporate Practice of Medicine Doctrine Comes First

The corporate practice of medicine doctrine, commonly abbreviated CPOM, holds that a corporation or unlicensed person may not practice medicine and may not employ a physician to practice medicine on its behalf. Its stated rationale is that clinical decisions should rest with licensed professionals rather than being influenced by non-physician owners whose interests may diverge from patient needs.

Roughly two-thirds of states recognize CPOM in some form, with widely varying enforcement. Several states enforce it strictly, including California, Texas, New York, and North Carolina. Others recognize it weakly. A small number have no meaningful doctrine, though they may still regulate related conduct such as fee-splitting.

What This Means Practically

In CPOM states, the entity that holds the right to practice medicine must be owned by licensed physicians, and only professional entities may deliver professional services. This is why most states bar physicians from using a standard LLC for clinical practice and require a PC or PLLC instead.

How Restrictive It Gets

The variation across states is substantial and the details matter.

• New York requires medical practices to be owned by physicians, without exceptions.
• California, under the Moscone-Knox Professional Corporation Act, prohibits general stock corporations, LLCs, and limited partnerships from practicing medicine or employing physicians to deliver medical services. Physicians must hold at least 51 percent of shares in a professional medical corporation, and the remaining shares may be held only by professionals in specifically enumerated licensed categories. Unlicensed individuals, including family members and outside investors, are categorically barred from any ownership interest.
• Georgia repealed its standalone prohibiting statute in 1982, but its Professional Corporation Act permits only licensed professionals actively practicing in the state to be shareholders of a professional corporation organized to provide medical services.
• Some states allow other licensed professionals, such as physician assistants or nurse practitioners, to hold minority ownership, often subject to a physician majority requirement.
• Florida has no CPOM doctrine, though fee-splitting and related restrictions still apply.

The Operating Assumption

Assume your state restricts ownership until you have confirmed otherwise. For a solo physician forming their own entity, CPOM is usually satisfied by definition, since a licensed physician owning their own professional entity is exactly what the doctrine contemplates. It becomes a live constraint the moment non-physicians, outside investors, or multi-state structures enter the picture, and it is the reason the answer to “what entity should I form” begins with your state’s professional entity statute rather than with a generic comparison chart.

Two Separate Decisions: Legal Entity and Tax Election

Keeping these straight resolves most of the confusion in this area.

Decision One: The Legal Entity

Formed under state law by filing with the Secretary of State. It determines who may own the practice, what governance formalities apply, how liability is allocated, and what the practice is called. For a medical practice this is usually a PC or a PLLC, and the available options are set by your state’s professional entity statutes.

Decision Two: The Tax Election

Made with the IRS, and largely independent of the entity choice. Both a PC and a PLLC can elect to be taxed as an S-Corporation. A PLLC may alternatively be taxed as a sole proprietorship or partnership by default. A PC defaults to C-Corporation treatment unless an S election is made, which is a meaningful trap discussed below.

Why the Distinction Matters

Physicians frequently believe they must choose between the liability characteristics of one option and the tax characteristics of another. In most cases they can have both, because the two decisions are made separately. Where the state permits both PC and PLLC formation, the practical difference between them is corporate formality and default tax treatment, not clinical capability or fundamental liability protection.

Who Does What: Assembling the Right Advisory Team

Entity selection sits at the intersection of three professions, and physicians frequently ask one of them to answer a question that belongs to another. Understanding the division of labor saves time, money, and a meaningful amount of avoidable risk.

The Healthcare Attorney

Only a licensed attorney can practice law, and several of the decisions in this article are legal decisions.

An attorney licensed in your state is the person who:

• Determines what the corporate practice of medicine doctrine permits in your state and how it applies to your specific situation
• Identifies which professional entity forms are available to you under state professional entity statutes
• Forms the entity, prepares and files articles of incorporation or organization, and satisfies any medical board registration requirements
• Drafts the operating agreement, bylaws, shareholder agreement, and buy-sell provisions
• Drafts and negotiates employment agreements, restrictive covenants, and physician buy-in documents
• Renders legal opinions on liability exposure, regulatory compliance, and transaction structure
• Structures MSO arrangements and reviews management services agreements

The Accountant and Practice Management Consultant

The financial and operational side of the decision belongs here.

Your accountant and practice management consultant are the people who:

• Model the financial consequences of each available tax election against your projected income
• Analyze and document reasonable compensation using specialty and regional benchmark data
• Project the interaction between compensation, retirement plan contributions, and the qualified business income phase-out
• Prepare and file the entity and individual tax returns once the structure is in place
• Build the chart of accounts, financial reporting, and profit center structure that a multi-owner compensation formula depends on
• Advise on the operational and economic implications of governance and compensation arrangements the attorney will document

Where the Two Overlap

The productive pattern is sequential and iterative. The attorney establishes what is legally permitted, which narrows the field. The accountant models the financial outcomes across the permitted options. The physician chooses. The attorney then documents the choice in properly drafted governing instruments, informed by the economic terms the accountant helped design.

Problems arise when this sequence collapses. A physician who forms an entity online without legal review may end up with an entity type their state does not permit for medical practice. A physician who forms a PC on an attorney’s advice without tax modeling may end up in C-Corporation status by default. A group whose compensation formula was drafted without accounting input frequently discovers the formula cannot be administered from the financial data the practice actually produces.

A Note on DoctorsManagement's Role

DoctorsManagement is a healthcare consulting, accounting, and auditing firm. It is not a law firm and does not practice law. We do not form entities, draft operating agreements or shareholder agreements, render legal opinions, or advise on whether a particular structure satisfies your state’s corporate practice of medicine requirements. Those are legal services and they require a licensed attorney.

What we do is the financial and operational half of the analysis, and we work alongside your attorney rather than in place of one. The section near the end of this article describes that scope precisely.

The Professional Corporation (PC)

The professional corporation, sometimes called a professional association or PA depending on the state, is the traditional entity for physician practices and remains the required or default form in a number of states.

Characteristics

• Formed under the state’s professional corporation act
• Ownership restricted to licensed professionals, frequently limited to the same profession
• Governed by a board of directors with officers, requiring corporate formalities
• Ownership expressed as shares of stock
• Defaults to C-Corporation tax treatment; an S election must be made affirmatively

Corporate Formalities

PCs carry more procedural obligation than PLLCs: bylaws, annual meetings, documented minutes, board resolutions for significant actions, and stock records. These are not merely administrative. Corporate formalities are part of what preserves the liability shield, and courts examining whether to disregard the entity look at whether formalities were observed.

Where the PC Fits

The PC is the right choice where state law requires it, where the practice anticipates multiple physician shareholders and wants the well-developed corporate governance framework that comes with stock, share transfers, and buy-sell mechanics, or where a future transaction is likely to favor a corporate form.

The Professional Limited Liability Company (PLLC)

The PLLC is the professional-entity analogue of the LLC, available in most but not all states.

Characteristics

• Formed under the state’s LLC act, with professional entity provisions applying
• Ownership restricted to licensed professionals, as with the PC
• Governed by an operating agreement rather than bylaws, with substantially more flexibility
• Ownership expressed as membership interests
• Defaults to pass-through treatment: disregarded entity for a single member, partnership for multiple members; an S election is available

The Flexibility Advantage

The operating agreement can allocate management authority, profit distributions, and voting rights with considerably more freedom than corporate structures generally permit. For practices where physicians contribute differently, whether in capital, patient volume, administrative role, or call coverage, this flexibility has real value.

Lighter Formality Requirements

PLLCs typically require fewer ongoing formalities than PCs. This reduces administrative burden, though it should not be mistaken for an absence of obligation. The operating agreement still needs to exist, be followed, and be updated as the practice changes.

Where the PLLC Fits

The PLLC is often the better choice for solo physicians and small groups in states that permit it, particularly where the practice values operational flexibility and wants to avoid corporate formality overhead. Its default pass-through treatment also avoids the C-Corporation default problem that catches PC owners.

The Standard LLC and Why It Usually Is Not Available

The standard LLC is the default recommendation in general small-business guidance, and for most businesses it is a sound one. For clinical medical practice it is usually unavailable.

In CPOM states, an unlicensed entity may not practice medicine or employ physicians to do so. A standard LLC formed through the ordinary filing process is an unlicensed entity. Attempting to operate a clinical practice through one in a state that requires a professional entity can create licensing exposure, contract enforceability problems, and complications in any future transaction.

Where a Standard LLC Does Appear

Standard LLCs are commonly used alongside a practice for functions that are not the practice of medicine:

• Real estate holding. Where physicians own the building, an LLC holding the real estate and leasing to the practice is a common and generally sound structure that separates the property from practice liability.
• Equipment holding. Similar logic, though the tax analysis differs and should be evaluated.
• Management services organizations. Discussed further below.
• Non-clinical ancillary ventures. Businesses that do not involve the practice of medicine may often use standard entities, subject to fee-splitting and referral-relationship analysis.

The distinction that matters is whether the entity is practicing medicine. Entities that hold assets or provide administrative services generally are not; entities that employ physicians to deliver clinical care generally are.

The S-Corporation Election

The S-Corporation is a federal tax election, not an entity type. It is available to both PCs and PLLCs that meet the eligibility requirements, and it is the most common tax structure for physician practices.

The Core Mechanic

An S-Corp owner who works in the business must be paid reasonable compensation as a W-2 employee. Profits distributed beyond that reasonable salary are not subject to self-employment tax. In a sole proprietorship or a partnership-taxed entity, by contrast, the owner’s entire net income is generally subject to self-employment tax.

The planning opportunity is the gap between reasonable compensation and total profit. Payroll taxes apply to the salary; the distribution portion escapes them.

The Reasonable Compensation Constraint

This is the element practitioners most often get wrong, and it is where audit exposure lives. Compensation must be reasonable for the services actually performed. A physician generating substantial clinical revenue who pays themselves an implausibly low salary in order to maximize distributions is taking a position the IRS regularly challenges and frequently defeats.

Reasonable compensation should be supported by reference to specialty and regional compensation benchmarks, the physician’s actual clinical productivity, hours worked, and the roles performed. The analysis should be documented rather than assumed, and it should be revisited as the practice’s economics change.

Eligibility Requirements

• No more than 100 shareholders
• Shareholders generally must be individuals who are U.S. citizens or residents
• Only one class of stock, which constrains differential economic arrangements among owners
• Timely filing of the election

The Single Class of Stock Limitation

For multi-physician practices contemplating tiered ownership, differential distributions, or preferred returns to founding partners, the single class of stock requirement is a genuine constraint. Partnership taxation permits allocation flexibility that S-Corp status does not. This trade-off between payroll tax savings and allocation flexibility is one of the more consequential decisions a growing group makes.

The C-Corporation and the Personal Service Corporation Trap

C-Corporation treatment means the entity pays tax on its income and shareholders pay tax again on distributions. This double taxation is generally unattractive for a practice that distributes most of its earnings.

The Default Problem

A professional corporation defaults to C-Corporation treatment unless an S election is filed. Physicians who form a PC and do not make the election, or who miss the filing deadline, may find themselves in C-Corp status without having chosen it. This is one of the more expensive unforced errors in practice formation and it is entirely preventable with competent guidance at formation.

Personal Service Corporation Status

A C-Corporation whose principal activity is performing services in health, and whose services are substantially performed by owner-employees, may be classified as a personal service corporation. Historically PSCs faced a punitive flat corporate rate. Following corporate rate changes the disparity narrowed, but PSC classification carries other consequences including limitations on accounting method and fiscal year selection.

When C-Corp Treatment Might Be Considered

Rarely for a straightforward clinical practice. It may enter the analysis where the practice intends to retain substantial earnings for expansion rather than distribute them, where certain fringe benefit treatments are valuable enough to outweigh the double taxation, or in specific transaction structures. These are situations that warrant modeling with a CPA rather than a default.

What Liability Protection Actually Covers

This is the most consistently misunderstood aspect of entity selection, and the misunderstanding runs in the direction of overconfidence.

What the Entity Does Protect

• Business debts and contractual obligations of the practice, including leases, vendor agreements, and loans that were not personally guaranteed
• Employment claims against the practice
• Premises liability, such as a patient injured in the waiting room
• Malpractice claims arising from another physician’s clinical conduct, where you were not personally involved and did not negligently supervise

What the Entity Does Not Protect

• Your own clinical malpractice. A physician remains personally liable for their own professional negligence regardless of entity form. No professional entity shields a clinician from their own clinical acts. This is the point most frequently misunderstood, and it is why malpractice insurance is the primary protection against clinical liability and the entity is not.
• Personally guaranteed obligations. Landlords and lenders routinely require personal guarantees from physician owners of new practices. A guaranteed obligation is a personal obligation.
• Unpaid payroll taxes. Responsible persons face personal liability for trust fund taxes withheld and not remitted.
• Your own fraudulent or criminal conduct, including healthcare fraud and abuse violations. Entity form provides no protection against False Claims Act liability, Anti-Kickback Statute exposure, or program exclusion.

Piercing the Veil

Liability protection depends on maintaining genuine separation between the practice and the owner. Courts disregard entities where owners commingle personal and business funds, fail to observe required formalities, undercapitalize the entity, or treat its assets as personal property. An entity that exists on paper but is operated as an extension of the physician’s checkbook provides substantially less protection than its owner assumes.

Maintain separate bank accounts, document distributions properly, observe the formalities your entity type requires, and keep the operating agreement or bylaws current and followed.

Tax Considerations for 2026

The One Big Beautiful Bill Act, signed in July 2025, reshaped several provisions that bear directly on entity and compensation planning for physician practices.

Section 199A Made Permanent

The 20 percent qualified business income deduction for pass-through entities is now permanent, eliminating the prior sunset. For pass-through practices this removes a significant planning uncertainty.

The SSTB Problem

The IRS classifies health as a specified service trade or business. This covers physicians, dentists, and other licensed healthcare providers, and it means the QBI deduction phases out as taxable income rises rather than being available at all income levels as it is for non-SSTB businesses.

A software company owner with $1 million of pass-through income may claim a QBI deduction subject to wage limitations. A physician with the same income generally receives nothing.

The 2026 Phase-Out Ranges

OBBBA widened the phase-in ranges, from $100,000 to $150,000 for joint filers and from $50,000 to $75,000 for others. With inflation indexing, the 2026 phase-out for married filing jointly runs from roughly $400,000 to roughly $550,000 of taxable income, with the single-filer range roughly half those figures. Below the lower bound the full deduction is available; above the upper bound an SSTB receives none; within the range it phases down on a sliding scale.

Published figures for the exact 2026 thresholds vary across sources, and they are indexed annually. Confirm current numbers with your CPA before relying on them for planning. The structural point is stable: the deduction is phased out for higher-earning physicians, and taxable income is the lever.

Why This Creates a Planning Opportunity

Because the phase-out keys off taxable income, anything that reduces taxable income can restore some or all of the deduction. Retirement plan contributions are the most powerful lever. A substantial solo 401(k) or cash balance plan contribution can move a physician from the upper end of the phase-out range into partial or full deduction territory, producing a benefit on top of the deferral itself.

This interaction is precisely why entity selection, compensation setting, and retirement plan design should be modeled together rather than decided in isolation.

Other Relevant Changes

• Minimum deduction. Beginning in 2026, a $400 minimum QBI deduction applies where the taxpayer has at least $1,000 of QBI and materially participates.
• SALT cap. The state and local tax deduction cap rose from $10,000 to $40,000 through 2029, subject to income limitations and phase-outs.
• Pass-through entity tax elections. Many states permit the practice to pay state income tax at the entity level, making it a deductible business expense and effectively working around the federal SALT cap. For multi-physician pass-through practices this is often worth more than the SALT cap increase itself.
• Equipment expensing. Section 179 expensing and 100 percent bonus depreciation remain available for qualifying equipment purchases, which affects the timing analysis on startup capital expenditures.

Multi-Physician Practices: Governance and Partnership Structure

For groups, the entity is only the container. The governing documents do the real work, and inadequate documents cause more practice disputes than entity selection ever does.

What the Operating Agreement or Shareholder Agreement Must Address

• Ownership and admission. Who may own an interest, how new physicians become owners, what the buy-in is, and over what period.
• Compensation methodology. How clinical production, ancillary revenue, administrative roles, and call coverage translate into compensation. This should be reduced to a formula rather than left to annual negotiation.
• Governance and voting. What decisions require unanimity, what requires a majority, and how deadlock is broken in an evenly held practice.
• Buy-sell provisions. What happens on death, disability, retirement, voluntary departure, or involuntary removal, including the valuation methodology and payment terms.
• Restrictive covenants. Non-competition and non-solicitation terms, subject to state enforceability limits, which vary considerably and have been in flux.
• Transfer restrictions. CPOM requires that ownership remain with licensed physicians, so the agreement must prevent interests from passing to unlicensed heirs. This is a compliance requirement, not merely a business preference.

The Valuation Provision

Buy-sell valuation should be defined by formula or by a specified appraisal process agreed in advance. Practices that leave valuation to be negotiated at the time of departure reliably discover that the departing physician and the remaining physicians hold irreconcilable views, and that the disagreement arrives at the least convenient moment.

The Tax Structure Interaction

The S-Corp single class of stock requirement constrains how differently owners can be treated economically. Groups that want tiered ownership, preferred returns, or special allocations may find partnership taxation a better fit despite forgoing payroll tax savings. Model both before committing, because converting later is possible but not costless.

Planning for the Exit: How Structure Affects a Future Sale

Most physicians forming a practice are not thinking about selling it. The structure chosen at formation nonetheless shapes what a transaction looks like a decade later.

The CPOM Constraint on Buyers

In states with strong CPOM enforcement, a private equity firm or ordinary corporation cannot directly purchase and own a clinical practice’s assets, because the entity holding the right to practice medicine must be physician-owned. Nor can such a buyer directly employ physicians to perform clinical services. This is why healthcare transactions in CPOM states use specialized structures rather than straightforward asset or stock purchases.

Asset Sale Versus Equity Sale

Buyers typically prefer asset purchases for liability and basis reasons. Sellers often prefer equity sales for capital gains treatment. Entity type and tax election affect how each is taxed, and C-Corporation status in particular can produce meaningfully worse seller outcomes in an asset sale. These consequences are set years before the transaction.

Practical Guidance

Even if a sale seems remote, avoid structures that foreclose options. Keep the entity clean, maintain proper records, keep ownership documentation current, and revisit the structure periodically as the practice grows. A practice contemplating a transaction within five years should model the tax consequences well in advance, because some optimizations require lead time.

The MSO Model and Why It Exists

The management services organization structure is the standard response to CPOM in transactions involving non-physician capital, and it is worth understanding even for physicians with no interest in outside investment.

How It Works

The structure separates clinical from non-clinical:

• The professional entity, a physician-owned PC or PLLC, employs the clinical providers and holds all clinical decision-making authority.
• The MSO, which may be owned by non-physicians, provides non-clinical services: administration, billing, human resources, technology, facilities, and management.
• A management services agreement governs the relationship, with the MSO compensated through fees that should be set at fair market value.

Why the Fee Structure Matters

The management fee is where these structures succeed or fail from a compliance standpoint. Fixed or cost-plus fees supported by a fair market value analysis are the safer approach. Fee arrangements that function as revenue sharing tied to clinical volume raise fee-splitting concerns and, where federal healthcare program business is involved, Anti-Kickback Statute exposure.

Where Value Accumulates

Because physician ownership of the professional entity is required, the PC itself is difficult to sell to a non-physician buyer. In MSO structures, enterprise value is built in the MSO, which can be bought and sold like any other business. This is the mechanism by which private equity participates in physician practices in CPOM states.

Telehealth and Multi-State Operations

CPOM applies in every state where care is delivered, which means telehealth operations serving multiple states may require physician-owned professional entities in each, linked to a central MSO. Regulators have scrutinized telemedicine structures closely, and physicians participating in them should understand what they are signing.

A Caution

MSO arrangements are legitimate and common, and they are also technically demanding. A physician presented with an MSO structure by a prospective investor should have independent counsel review it. The structure determines who controls clinical decisions, how the physician is compensated, what happens if the relationship ends, and whether the arrangement withstands regulatory scrutiny.

A Decision Framework

Work through these in order. The bracketed note on each step identifies which advisor owns it.

• Determine what your state permits. Identify whether your state recognizes CPOM and which professional entity forms are available for medical practice. This narrows the field before any other analysis, and in some states it decides the question outright. [Healthcare attorney]
• Choose between PC and PLLC where both are available. PLLCs generally offer more governance flexibility and lighter formality requirements with pass-through default treatment. PCs offer a well-developed corporate framework that some multi-owner groups and some future transactions favor. [Attorney on what is permitted and the liability and governance implications; accountant on the tax consequences of each]
• Model the tax election. Run the S-Corp analysis against your projected income and a defensible reasonable compensation figure. Include the QBI phase-out interaction and retirement plan contributions in the same model, because they move together. [Accountant]
• Address multi-owner economics before formation. If the practice will have more than one owner, determine whether the S-Corp single class of stock constraint is compatible with your intended compensation and ownership arrangements. [Accountant models the economics; attorney confirms what the entity form and election permit]
• Draft governing documents that reflect actual intent. The operating agreement or shareholder agreement is where the practice’s real terms live. Template documents that were never customized are the source of most partnership disputes. [Attorney drafts; accountant confirms the compensation formula can be administered from actual financial data]
• Separate non-clinical assets. Consider holding real estate and, where appropriate, significant equipment in separate entities. [Attorney forms the entities and papers the lease; accountant models the tax treatment]
• Build in a review cadence. Revisit the structure when income changes materially, when owners join or leave, when tax law changes, and when a transaction becomes plausible. [Accountant leads the annual review and flags when legal review is warranted]

How DoctorsManagement Supports Entity and Tax Planning

DoctorsManagement is a full-service healthcare consulting, accounting, and auditing firm. We are not a law firm and we do not practice law. We have worked with physician-owned practices since 1956, and our accounting team works exclusively with medical practices, which means our analysis reflects how practices actually generate, allocate, and distribute income rather than generic small-business assumptions.

What We Do

• Tax Election Modeling: Financial analysis of S-Corporation versus pass-through treatment against your projected practice income, so you can evaluate the economic consequences of each option your attorney confirms is available to you
• Reasonable Compensation Analysis: Compensation determination supported by specialty and regional benchmark data, documented to withstand IRS examination
• Tax Planning and Strategy: Retirement plan design, equipment purchase and depreciation timing, estimated tax projection and safe harbor planning, pass-through entity tax election analysis, and multi-year modeling
• Tax Return Preparation and Filing: Entity and individual returns including Forms 1065, 1120S, 1120, and 1040, with filings coordinated across personal returns, practice entities, and related real estate or holding companies
• Accounting and Bookkeeping: Reconciled books, ongoing ledger review for reasonableness and IRS compliance, payroll, and monthly management reporting built on profit center data
• Compensation Model Design and Reporting: Custom reporting that reflects each owner’s agreed compensation model, including salary plus productivity arrangements, so that the formula your attorney documents can actually be administered from your financial data
• Practice Management Consulting: Operational and financial guidance across the practice lifecycle, including startup, growth, transition, and succession
• Transition and Succession Support: Financial modeling for partner buy-in and buy-out, practice valuation input, and economic analysis ahead of a sale or transition

What We Do Not Do

These are legal services. They require an attorney licensed in your state, and we will tell you so rather than attempt them.

• We do not form entities or file articles of incorporation or organization
• We do not draft operating agreements, bylaws, shareholder agreements, buy-sell provisions, or employment contracts
• We do not render legal opinions on corporate practice of medicine compliance or on which entity forms your state permits
• We do not provide legal advice on liability exposure, restrictive covenants, or regulatory interpretation
• We do not structure or paper MSO arrangements, management services agreements, or transaction documents
• We do not represent practices in legal proceedings or negotiate legal terms on your behalf

How We Work With Your Attorney

Most physicians we work with have healthcare counsel, and where they do not, we encourage them to retain one before formation. Our role is to supply the financial analysis that makes the legal decisions better informed, and then to build the accounting and reporting infrastructure that the resulting structure requires.

In practice this means your attorney tells you what you may do, we model what each option costs and produces, you decide, your attorney documents it, and we account for it from there. If you need a referral to healthcare counsel, we can point you toward attorneys experienced with physician practices in your state.

To discuss the accounting, tax, and practice management side of your structure, contact DoctorsManagement at www.doctorsmanagement.com/accounting-services or call (800) 635-4040.

Frequently Asked Questions

Can I form a regular LLC for my medical practice?

In most states, no. The corporate practice of medicine doctrine requires a professional entity, meaning a PC or PLLC owned by licensed physicians, and bars unlicensed entities from practicing medicine or employing physicians to do so. Standard LLCs are commonly used alongside a practice for real estate holding, equipment holding, or management services, but generally not for the clinical practice itself. Confirm your state’s requirements before forming anything.

What is the difference between a PC and a PLLC?

Both restrict ownership to licensed professionals and both provide comparable liability protection. A PC is governed by bylaws and a board with stock ownership, carries more corporate formality, and defaults to C-Corporation tax treatment. A PLLC is governed by an operating agreement with membership interests, offers more structural flexibility and lighter formalities, and defaults to pass-through treatment. Where both are available, the difference is corporate formality and default tax treatment, not clinical capability.

Is an LLC or an S-Corp better for a medical practice?

The question compares two different things. An LLC or PLLC is a legal entity formed under state law; an S-Corporation is a federal tax election. A PLLC or PC can elect S-Corp taxation. The real questions are which professional entity your state permits, and then how that entity should be taxed.

How does S-Corp election save on taxes?

An S-Corp owner working in the business must be paid reasonable W-2 compensation, and profits distributed beyond that are not subject to self-employment tax. The savings come from the gap between reasonable compensation and total profit. The constraint is that compensation must genuinely be reasonable for the services performed, supported by benchmark data and documented. Understating salary to maximize distributions is a position the IRS regularly challenges.

Does my entity protect me from malpractice claims?

Not from your own. A physician remains personally liable for their own professional negligence regardless of entity form. The entity can protect against business debts, contractual obligations, premises liability, and in many cases another physician’s malpractice where you were not personally involved. Malpractice insurance, not entity structure, is the primary protection against clinical liability.

Can physicians claim the QBI deduction?

Sometimes. Medicine is a specified service trade or business, so the 20 percent deduction phases out as taxable income rises. For 2026 the married filing jointly phase-out runs roughly from $400,000 to $550,000 of taxable income, with the single range roughly half that, though published figures vary and thresholds are indexed annually. Below the range the full deduction is available; above it an SSTB receives none. Retirement plan contributions that reduce taxable income can restore some or all of it, which is why these decisions should be modeled together. Confirm current thresholds with your CPA.

What happens if I form a PC and forget to make the S election?

The PC defaults to C-Corporation treatment, meaning the entity pays tax on its income and shareholders pay again on distributions. For a practice that distributes most of its earnings this is generally an unfavorable outcome. It is one of the more expensive and more preventable formation errors, and it argues for making the entity and election decisions together with professional guidance at the outset.

Can non-physicians own part of my practice?

In CPOM states, generally not. California, for example, categorically bars unlicensed individuals including family members and investors from holding any ownership interest in a professional medical corporation, and requires physicians to hold at least 51 percent of shares. Some states permit other licensed professionals such as PAs or NPs to hold minority interests. Non-physician capital typically participates through a management services organization rather than through practice ownership.

Should I hold my office building in the practice entity?

Generally not. Holding real estate in a separate entity, commonly a standard LLC, that leases to the practice separates the property from practice liability and preserves flexibility if the practice is later sold or dissolved. The lease should be at fair market value and documented, particularly given referral-relationship and fair market value considerations in healthcare.

Do I need both an attorney and an accountant for this decision?

Yes, and they answer different questions. An attorney licensed in your state determines what the corporate practice of medicine doctrine permits, which entity forms are available to you, forms the entity, and drafts the governing documents. An accountant models the financial consequences of the available tax elections, analyzes reasonable compensation, and handles the returns. Attempting the decision with only one of the two is how physicians end up in entity types their state does not permit, or in C-Corporation status they never intended.

Can DoctorsManagement form my entity or give me legal advice?

No. DoctorsManagement is a healthcare consulting, accounting, and auditing firm, not a law firm, and we do not practice law. We do not form entities, draft operating agreements or shareholder agreements, render legal opinions on corporate practice of medicine compliance, or provide legal advice of any kind. Those services require an attorney licensed in your state. What we provide is the financial and operational analysis that supports the decision, along with tax planning, return preparation, accounting, and practice management consulting once the structure is in place. We work alongside your attorney, not in place of one.

How can DoctorsManagement help with entity and tax decisions?

We model the financial consequences of each tax election your attorney confirms is available, analyze and document reasonable compensation against specialty benchmarks, project the interaction between compensation, retirement contributions, and the QBI phase-out, and prepare the entity and individual returns. We also provide bookkeeping, payroll, monthly management reporting, compensation model design and reporting, and practice transition support. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• IRS Discussion of the Corporate Practice of Medicine
• IRS Section 179 Deduction Information
• American Medical Association Private Practice Resources
• Medical Group Management Association (MGMA)
• OIG Fraud and Abuse Laws for Physicians
• American Health Law Association (AHLA)
• DoctorsManagement Accounting Services
• DoctorsManagement Practice Startup Services
• DoctorsManagement Credentialing Services

Corporate practice of medicine requirements, professional entity statutes, and tax thresholds vary by state, change over time, and are subject to annual inflation indexing and legislative revision. The figures cited reflect published sources at the time of writing and should be independently confirmed. Entity selection and formation should be undertaken with a healthcare attorney licensed in your state, working alongside an accountant experienced with physician practices. DoctorsManagement is available to provide the accounting, tax planning, and practice management consulting components of that work.

Contact Us

This article is provided for informational and educational purposes only. It does not constitute legal advice, tax advice, or financial advice, and it does not create any professional relationship. DoctorsManagement is a healthcare consulting, accounting, and auditing firm. It is not a law firm and does not practice law, form business entities, draft governing documents, or render legal opinions.

The post Choosing the Right Medical Practice Business Structure: LLC, PC, PLLC, and S-Corp Compared appeared first on DoctorsManagement.

Introduction: The Line Item That Does Not Appear in Your Budget

A physician planning a new practice will budget carefully for the things that are visible. Leasehold improvements have contractor quotes attached. Equipment has vendor pricing. Rent has a lease. Payroll has offer letters. Every one of these appears in the pro forma because every one of them arrives as an invoice.

Credentialing does not arrive as an invoice. It arrives as an absence. The practice opens, the physician sees patients, the claims go out, and nothing comes back, because the practice is not yet participating with the payers those patients are insured by. There is no bill to point at. There is simply revenue that does not exist, month after month, while every fixed cost continues on schedule.

This is why credentialing is the single largest cause of cash flow failure in new medical practices. Not because it is expensive, but because it is slow, and because physicians consistently underestimate how slow. The full path from starting a credentialing file to holding an effective participation date with a commercial payer commonly runs 90 to 180 days. For a practice building relationships with eight or ten payers, those timelines run in parallel but they do not run identically, and the practice is not fully operational until the last one closes.

The good news is that credentialing is the one major startup bottleneck that is almost entirely within the practice’s control. Construction can be delayed by permitting. Equipment can be delayed by supply chains. Credentialing is delayed, in the overwhelming majority of cases, by starting late and by submitting incomplete applications. Both are avoidable.

This guide covers the entire workflow: NPI, licensure, CAQH, Medicare, Medicaid, and commercial payer contracting. It explains what each step actually requires, how long each realistically takes, where the effective date rules create hard financial consequences, what changed in PECOS in 2026, and how to model the revenue gap so that it is funded rather than discovered.

Credentialing and Enrollment Are Two Different Things

These terms are used interchangeably in conversation and they refer to distinct processes with different requirements and different timelines. Conflating them is the source of a good deal of confusion about where an application actually stands.

Credentialing

Credentialing is verification. It is the process by which a payer, hospital, or health system independently confirms that a clinician possesses the education, training, licensure, board certification, malpractice history, and professional work experience required to deliver care. It is required by CMS, NCQA, and The Joint Commission as a precondition of network participation.

The defining feature of credentialing is primary source verification, meaning the verifying organization confirms each credential directly with the issuing institution rather than accepting copies from the provider.

Enrollment and Contracting

Enrollment is the administrative process of registering the provider and the practice entity with a payer so that claims can be submitted and paid. Contracting is the execution of a participation agreement establishing the terms, including the fee schedule.

A provider can be fully credentialed and still be unable to bill, because the contract has not been executed or the enrollment record is not linked correctly. Practices regularly discover this after the fact, having been told credentialing was approved and then finding claims rejecting.

Why the Distinction Matters Operationally

When following up on an application, the useful question is not whether the provider is credentialed. It is whether there is an effective participation date, whether the contract is executed, and whether the provider is correctly linked to the group’s tax identification number in the payer’s system. Those are three separate confirmations and all three are required before a claim will pay.

The Real Timeline: What 90 to 180 Days Actually Looks Like

Published credentialing timelines vary because the processes vary. The following reflects realistic ranges for a clean file.

• NPI (Type 1 and Type 2): Days. Often same day to two weeks through NPPES.
• CAQH ProView profile build and attestation: One to three weeks, depending on how quickly the provider supplies documentation.
• Medicare via PECOS: Roughly 45 to 65 days for a clean electronic application. Paper applications run substantially longer, commonly 90 to 120 days. Roughly 40 percent of applications require corrections, which adds 15 to 30 days or more.
• Medicaid: Highly state-dependent, commonly 60 to 120 days, and some states require Medicare enrollment first.
• Commercial payer credentialing review: Typically 60 to 120 days after CAQH data is authorized to the payer, under NCQA standards. Clean, complete profiles can close in 45 to 60 days.
• Contract execution and loading: Two to six weeks after credentialing approval, and this step is frequently omitted from provider estimates.

Total elapsed time from beginning CAQH setup to holding an effective participation date is commonly 90 to 180 days per payer. Because payers are worked in parallel, the practice’s functional readiness is governed by the slowest payer in the set, not the average.

The Compounding Problem

Credentialing delay does not end when the effective date arrives. Claims submitted after that date still move through normal adjudication and payment cycles, typically 30 to 45 days for a clean claim. A practice that achieves an effective date on day 120 is not receiving meaningful cash until roughly day 150 to 165, and is not at steady-state collections until the accounts receivable pipeline fills.

This is why startup working capital planning should assume six to twelve months of full operating expense coverage rather than the three to four months that credentialing timelines alone might suggest.

Step 1: The NPI, and Why Type 1 and Type 2 Both Matter

The National Provider Identifier is the foundation of the entire process. Nothing downstream moves without it. It is obtained at no cost from CMS through the National Plan and Provider Enumeration System.

Two Types, Both Usually Required

• Type 1 NPI: The individual provider. Tied to the person and their Social Security Number, and it follows them throughout their career regardless of where they practice.
• Type 2 NPI: The organization. Tied to the practice entity and its Employer Identification Number.

A physician billing under a group generally needs both. The individual renders and is identified as the rendering provider; the group bills and is identified as the billing provider. A new practice therefore needs a Type 2 NPI for the entity in addition to whatever Type 1 the physician already holds.

Sequencing Note

The Type 2 NPI requires the practice entity to exist and to have an EIN, which means entity formation must precede it. This is one of several places where the startup sequence is genuinely rigid: entity formation, then EIN, then Type 2 NPI, then enrollment applications. A practice that delays entity formation delays everything downstream by the same amount.

Data Consistency Is Not Optional

The legal name, address, taxonomy code, and EIN in the NPPES record must match what appears in PECOS, in CAQH, and on IRS records. Mismatches between these systems are among the most common causes of application delay, and they are frustrating precisely because the application is not wrong in substance, only inconsistent across databases.

Establish the exact legal name and practice address once, in writing, and use that identical string everywhere. Variations as minor as “Suite 200” versus “Ste 200” have generated development requests.

Step 2: State Licensure, DEA, and the Prerequisite Chain

Payer enrollment requires an active, unrestricted license in the state of practice. Where a physician is licensing in a new state, that timeline governs everything else and should be started first.

The Prerequisite Chain

• State medical license, active and unrestricted in the state where services will be rendered
• DEA registration, with the practice address, where controlled substances will be prescribed
• State controlled substance registration where the state requires one separate from DEA
• Malpractice coverage meeting payer minimums, with a certificate of insurance naming the practice entity
• Hospital privileges or a documented admitting arrangement, where the payer requires it

Two Common Sequencing Failures

The DEA registration must show the practice address. A physician who registers the DEA at a prior employer’s address, or at a home address, will need to update it, and payers will flag the discrepancy.

Malpractice coverage must name the new entity, not a prior employer. Payers verify coverage and the certificate must match the entity being enrolled. Coverage that has not been bound because the practice has not opened yet is a genuine chicken-and-egg problem, and the answer is usually to bind coverage effective as of the anticipated open date and obtain a certificate reflecting it.

An Important Constraint on Retroactivity

For Medicare, the effective date cannot precede the date the provider obtained all required credentials. Retroactive billing windows do not reach back past licensure. A provider whose license issued on the fifteenth cannot have a Medicare effective date before the fifteenth regardless of when the application was filed.

Step 3: Building the CAQH ProView Profile

CAQH ProView is the centralized credentialing data repository used by most commercial payers in the United States. Rather than submitting separate credential packets to every payer, providers maintain a single profile that participating insurers access when processing enrollment applications. It is used by millions of providers and queried by essentially every commercial payer pursuing NCQA accreditation.

As of mid-2026, CAQH’s parent organization rebranded as DataSpring, powered by CAQH. The login, profile, and documents at proview.caqh.org carry over unchanged, and the practical process is the same.

What the Profile Contains

• Personal and demographic information
• Education, training, internship, residency, and fellowship history
• Complete work history, with explanations for any gaps
• State licenses, DEA registration, and board certifications
• Malpractice insurance coverage and claims history
• Practice locations, hours, and languages spoken
• Hospital affiliations and admitting arrangements
• Disclosure questions covering license actions, criminal history, and malpractice claims
• Supporting documents uploaded as attachments

Completeness Is Worth Weeks

Providers with fully completed profiles routinely see credentialing turnaround 30 to 45 days faster than those with incomplete or outdated profiles. The reason is straightforward. A payer that finds a gap does not simply proceed; it generates an outreach request, and the file sits until the provider responds.

Work history gaps deserve particular attention. Any unexplained period will generate a follow-up. Account for every month, including research years, parental leave, military service, and periods of unemployment. A one-line explanation entered proactively costs nothing; the same explanation supplied reactively costs two to four weeks.

Authorization

Building the profile is not sufficient. The provider must authorize specific payers to access it. An immaculate profile that no payer is authorized to view does not advance any application.

The 120-Day Attestation Cycle and How Practices Lose Months to It

CAQH requires re-attestation every 120 days, whether or not anything has changed.

Attestation is an affirmative act. The provider logs in, confirms that all data remains current and accurate, and electronically signs. Missing the window marks the profile as outdated or inactive.

Why This Is So Costly

The damage from a lapsed attestation is quiet, which is exactly what makes it dangerous. Claims continue to process for payers where the provider is already enrolled. Patients continue to be scheduled. Nothing generates an alert. The only thing that stops is forward motion: applications in progress freeze, recredentialing cycles stall, and any payer querying the profile during the lapse cannot retrieve the data.

For a practice in the middle of credentialing eight payers, a lapsed attestation can silently suspend all eight simultaneously. The practice discovers it weeks later when following up and learns that nothing has moved.

Downstream Effects

Payer directories may drop the listing. Payers that monitor CAQH status in real time may place claims on hold until the profile is reactivated and re-attested. Recredentialing pulls use whatever data is on file at the time, so a lapse in the months preceding a recredentialing cycle can delay that cycle by 30 to 60 days while the provider re-attests and the payer reschedules the review.

The Fix

Calendar the attestation date for every provider at 100 days rather than 120, assign a named owner, and treat it as a recurring obligation with the same seriousness as license renewal. Practices that maintain CAQH consistently rarely have recredentialing problems. Practices with stale data routinely face 30 to 90 day delays.

Step 4: Medicare Enrollment Through PECOS

Medicare enrollment runs through the Provider Enrollment, Chain, and Ownership System. PECOS mirrors the paper CMS-855 form family electronically and is the faster and more reliable path by a wide margin.

Electronic Versus Paper

Clean PECOS applications are commonly processed in roughly 45 to 65 days. Paper applications submitted to the MAC commonly run 90 to 120 days. PECOS also validates required fields during entry, reducing incomplete-application rejections, and provides trackable status. There is almost no scenario in which paper is the better choice for a new practice.

The Correction Problem

Roughly 40 percent of applications require corrections, adding 15 to 30 days each time. The leading causes are consistent and preventable: NPI data mismatches between NPPES and the application, incomplete practice location information, missing signatures, and missing supporting document uploads that trigger MAC outreach.

PTAN

A provider cannot submit Medicare claims until the Provider Transaction Access Number is issued, which occurs only after CMS approves the enrollment application. The PTAN, not the approval notice, is the operative marker for billing readiness.

Application Fee

The 2026 Medicare enrollment application fee is $750, applying to institutional providers and DMEPOS suppliers for new enrollments, revalidations, and practice location changes. Individual practitioners enrolling through the CMS-855I generally do not pay the institutional application fee. Where a fee applies and is not paid, the MAC will allow a defined period to pay before rejecting or denying the application, and a hardship exception may be requested.

Choosing the Right CMS-855 Form

Filing the wrong form restarts the process. This adds 30 to 60 days and is entirely avoidable.

• CMS-855I: Individual physicians and non-physician practitioners.
• CMS-855B: Clinics, group practices, corporations, partnerships, professional associations, and similar organizations, plus certain suppliers.
• CMS-855R: Reassignment of benefits, used when an individual provider reassigns the right to bill to a group.
• CMS-855A: Institutional providers including hospitals, skilled nursing facilities, and home health agencies.
• CMS-855S: DMEPOS suppliers.
• CMS-855O: Providers who do not bill Medicare but must enroll in order to order or refer.

The Case Practices Trip On

A physician joining or forming a group requires three filings, not one. The physician files an 855I for themselves. The group is enrolled through an 855B. And an 855R reassigns the physician’s billing rights to the group.

Practices routinely file the 855I, wait for approval, and only then file the 855R, adding weeks unnecessarily. The 855R should be submitted the same day as the 855I wherever the sequence permits.

Medicare Effective Dates and the 30-Day Retroactive Window

Effective date rules differ by application type, and the differences carry direct financial consequences.

CMS-855I: Limited Retroactivity

For initial individual enrollments, the effective date can be retroactive up to 30 days before the date CMS receives the signed application. It cannot precede the date the provider obtained all required credentials.

Thirty days is the entire cushion. It is not a meaningful buffer against a late start; it is a modest allowance for the interval between filing and approval.

CMS-855B: Generally No Retroactivity

For group enrollment, the effective date is typically the date CMS receives the completed application, with no retroactive billing permitted. The date the entity’s application lands is the date the entity’s Medicare participation begins.

CMS-855R: The Later of Two Dates

For reassignments, the effective date is based on the later of the group’s effective date or the receipt date of the 855R. This is why filing the 855R promptly matters. A group with a favorable effective date gains nothing if the reassignment was filed six weeks later, because the later date controls.

The Timely Filing Backstop

Claims held pending enrollment must still be submitted within the Medicare timely filing limit of twelve months from the date of service. Practices that hold claims while waiting on enrollment should track the oldest date of service carefully, because a claim that becomes untimely is not payable regardless of enrollment status.

What PECOS 2.0 Changed in 2026

CMS migrated to PECOS 2.0 in 2026. The fundamentals are unchanged: the same CMS-855 forms apply, and revalidation cycles still run five years for most providers. Three changes affect how practices should manage enrollment.

Real-Time Validation

The system validates data during entry against CMS records. This is generally helpful, catching mismatches before submission rather than weeks afterward. It also means that discrepancies which previously passed unnoticed now surface immediately, and records that have drifted out of alignment will produce errors.

Stay of Enrollment

A Stay of Enrollment is a payment freeze applied when validation identifies a discrepancy in a provider’s record. The provider remains technically enrolled but cannot bill until the issue is resolved. For a practice dependent on Medicare volume, a stay produces the same operational effect as a suspension while carrying a less alarming name.

Retroactive Revocation

Under rules effective January 1, 2026, CMS can revoke a Medicare enrollment retroactively and recoup payments already made. This authority materially raises the stakes on enrollment record accuracy and on the timely reporting of reportable events.

What Practices Should Do

• Verify that the primary contact email on the PECOS record is active and monitored, since notifications go to that address and a departed employee’s mailbox means missing everything
• Confirm that adverse legal actions, ownership changes, and other reportable events are current in the record
• Reconcile NPPES, PECOS, CAQH, and IRS records so that names, addresses, and identifiers match exactly
• Treat the 30-day reporting windows for organizational changes as firm deadlines rather than administrative housekeeping

Step 5: Medicaid Enrollment

Medicaid enrollment is administered at the state level, and the variation is substantial. Each state maintains its own portal, its own requirements, and its own processing timeline, commonly 60 to 120 days.

Points of Variation

• Medicare-first requirements. Some states require Medicare enrollment to be complete before accepting a Medicaid application, which serializes two long processes.
• Retroactive enrollment. Some states permit retroactive effective dates; others do not. This single variable can be worth months of revenue and should be confirmed at the outset.
• Managed care organizations. In most states, enrolling with the state Medicaid program is only the first step. Each Medicaid managed care plan requires separate credentialing and contracting, and those timelines run after state enrollment completes.
• Site visits and screening levels. Provider screening categories determine whether fingerprinting or site visits are required, which extends the timeline.

Practical Guidance

Determine early whether Medicaid is material to your projected payer mix. If it is, treat state enrollment and each managed care plan as separate line items on the credentialing tracker with independent timelines. Practices frequently model Medicaid as one step and discover it is four.

Step 6: Commercial Payer Credentialing and Contracting

Commercial payers represent the majority of revenue for most practices and the longest tail on the credentialing timeline.

The Sequence Per Payer

• Submit an application or request for participation, which for many payers begins with a network interest inquiry
• Authorize the payer to access the CAQH ProView profile
• Complete payer-specific supplemental forms, which exist even where CAQH is used
• Payer conducts primary source verification and credentialing committee review, commonly 60 to 120 days
• Contract negotiation and execution, including fee schedule review
• Loading into the payer’s claims system and confirmation of the effective date

Network Closure

A payer may decline to add a provider because the network is closed for that specialty in that geographic area. This is a business decision, not a credentialing outcome, and it is worth determining early. Where a network is closed, options include requesting reconsideration based on access or subspecialty need, engaging through an existing group’s contract, or planning around the exclusion. A practice that assumes it will participate with every major payer and learns otherwise in month four has a payer mix problem in addition to a timeline problem.

Do Not Skip the Contract Review

The participation agreement establishes the fee schedule, the term, termination provisions, timely filing requirements, audit and recoupment rights, and dispute resolution. Practices under time pressure sign to unblock the timeline and then operate for years under terms they never evaluated. Requesting and reviewing the fee schedule before execution is a basic step and is frequently omitted.

Track Everything

Maintain a credentialing matrix recording, for each payer: date submitted, application or reference number, contact name, expected timeline, follow-up dates, current status, credentialing approval date, contract execution date, and effective date. Without systematic tracking, applications stall silently. Payers rarely reach out to say an application is waiting on something.

Primary Source Verification: What Payers Are Actually Doing

Primary source verification is the technical and regulatory core of credentialing and the most time-intensive stage. It requires independently confirming each credential directly with the original issuing institution. Copies supplied by the provider and self-reported information do not satisfy it.

What Gets Verified and Where

• Medical education, verified with the degree-granting institution
• Residency and fellowship training, verified with the sponsoring program
• State licensure, verified with the state licensing board
• Board certification, verified with the certifying board
• DEA registration
• Malpractice claims history and adverse actions, including a National Practitioner Data Bank query
• Work history and hospital affiliations

Timing Standards

Under NCQA’s updated standards, primary source verification must be completed within defined windows, and verifications that age out must be repeated. This has a practical consequence: a file that stalls for an extended period may require re-verification of elements that were already confirmed, which resets work rather than merely delaying it. Momentum has value.

Why Foreign Training and Older Records Take Longer

Verification depends on the responsiveness of the issuing institution. International medical graduates, physicians whose training programs have closed or merged, and providers with lengthy work histories across many institutions all encounter longer verification cycles. Where these factors apply, build additional time into the plan rather than treating the standard range as applicable.

Modeling the Revenue Impact of the Credentialing Gap

The credentialing gap should appear in the pro forma as an explicit assumption rather than as an unpleasant surprise.

A Simplified Model

Consider a solo physician projecting 18 patient encounters per day, four days per week, at an average net collection of $110 per encounter. At full schedule, that is roughly 72 encounters weekly and approximately $8,000 per week, or about $34,000 per month, in eventual collections.

Now apply the timeline. Assume commercial payers reach effective dates on a staggered basis between day 100 and day 165, and that claim payment lags 30 to 45 days behind the date of service. The practice may see negligible collections in months one through three, partial collections in months four and five as individual payers come online, and something approaching steady state in month six or seven.

Against that, fixed costs run continuously from the day the lease commences. Rent, payroll, malpractice, technology subscriptions, and loan service do not stagger.

The Planning Conclusion

Working capital reserves should be sized to cover six to twelve months of full operating expense, not three. A practice that opens with four months of reserves and encounters a single payer delay is in a genuine liquidity crisis by month five, at exactly the moment when the practice most needs stability.

The alternative framing is more useful still: every week of credentialing delay is a week of full operating cost incurred against zero corresponding revenue. For the practice above, that is roughly $8,000 of eventual collections deferred plus the operating expense burned in the same week. Compressing the credentialing timeline by a month is worth a substantial amount of real money, which is why professional management of the process routinely pays for itself.

Strategies for Generating Revenue During the Gap

The gap can be narrowed and partially bridged. None of these strategies eliminates it.

Start Absurdly Early

The most effective strategy by a wide margin. Begin primary source verification and CAQH setup as early as the file permits, ideally 120 or more days before the intended start date, and submit payer applications within about two weeks of completing CAQH attestation. Waiting until the practice opens to begin enrollment guarantees months of lost revenue.

Use the Medicare Retroactive Window Deliberately

The 30-day retroactive allowance on the CMS-855I has real value if the filing date is managed intentionally relative to the anticipated start of services. It is a small window and it rewards precision.

Hold Claims Rather Than Writing Them Off

Where an effective date is expected to be retroactive to a point covering services already rendered, claims can be held and submitted once the enrollment is active. Track the timely filing limit carefully, and confirm that the payer’s effective date genuinely covers the dates of service before relying on this.

Consider Cash-Pay and Non-Covered Services

Services that do not depend on payer participation can generate revenue during the gap. This is more viable for some specialties than others and should be structured carefully so that it does not create compliance issues with respect to patients who are Medicare beneficiaries.

Evaluate Locum Tenens and Reciprocal Billing Arrangements

Medicare permits certain substitute physician billing arrangements under defined conditions. These are technical, they carry specific documentation and duration requirements, and they are not a general workaround for an unenrolled provider. Where applicable, they should be structured with knowledgeable guidance.

Size the Credit Facility for the Real Timeline

A line of credit sized against a realistic credentialing timeline, arranged before the practice opens, is materially cheaper and easier to obtain than emergency financing arranged in month five under duress.

The Ten Most Common Credentialing Mistakes

• Starting too late. The single largest cause of revenue loss in new practices. Credentialing should begin months before the doors open, in parallel with build-out rather than after it.
• Data mismatches across NPPES, PECOS, CAQH, and IRS records. Establish the exact legal name, address, and identifiers once and use the identical string everywhere.
• Filing the wrong CMS-855 form. Requires starting over and adds 30 to 60 days.
• Filing the 855R after the 855I is approved. The reassignment effective date is the later of the group’s date or the 855R receipt date. Submit both together.
• Letting CAQH attestation lapse. Silently freezes every application in progress across every payer.
• Incomplete work history. Unexplained gaps generate outreach requests that add weeks. Account for every month proactively.
• Failing to authorize payers in CAQH. A complete profile that no payer can access advances nothing.
• Assuming credentialing approval means billing readiness. Contract execution and system loading follow approval and add two to six weeks.
• Not tracking applications systematically. Payers do not proactively report that a file is stalled. Without a matrix and scheduled follow-up, applications sit.
• Missing revalidation and recredentialing deadlines. Medicare deactivation and payer termination are far more disruptive than the original enrollment, and reinstatement is not instantaneous.

Ongoing Obligations: Revalidation, Recredentialing, and Change Reporting

Credentialing is not a project with a completion date. It is a permanent operational function.

Medicare Revalidation

Medicare requires revalidation of enrollment every five years for most provider types. Failure to respond to a revalidation request results in deactivation of billing privileges and a stop on payments. Reinstatement takes time, during which claims do not pay. Revalidation notices go to the address and email on the enrollment record, which is another reason to keep contact information current.

Commercial Recredentialing

NCQA-accredited health plans must recredential network providers at least every three years, and many payers operate on shorter cycles. The recredentialing pull uses whatever CAQH data is on file at the time, which is why the 120-day attestation discipline matters continuously rather than only during initial enrollment.

Recredentialing typically includes updated primary source verification of licensure, DEA, board certification, and malpractice coverage, an NPDB query for new adverse actions or claims, and review of any new disclosure events.

Change Reporting

Reportable changes carry deadlines, and Medicare requires reporting of many organizational changes within 30 days. Changes that must be reported commonly include:

• Practice location additions, closures, or relocations
• Changes in ownership or managing control
• Adverse legal actions
• Changes to the practice’s legal business name or tax identification number
• Banking information changes affecting electronic funds transfer
• Providers joining or leaving the group

Under the retroactive revocation authority effective in 2026, unreported changes carry more consequence than they previously did. A practice that has not filed required updates is exposed in a way it was not before.

Provider Onboarding and Offboarding

Every new provider added to the practice restarts the credentialing timeline for that provider. A physician hired to start in ninety days should have credentialing initiated at signature, not at start date. Similarly, departing providers must be removed from payer rosters and their reassignments terminated, or the practice retains exposure for claims billed under an inactive arrangement.

A Practical Credentialing Timeline for a New Practice

The following works backward from an intended opening date.

Six Months Before Opening

• Complete entity formation and obtain the EIN
• Obtain the Type 2 organizational NPI; confirm the Type 1 individual NPI record is current
• Confirm state licensure is active in the practice state; initiate licensure if not
• Update DEA registration to the practice address
• Bind malpractice coverage effective as of the anticipated open date and obtain the certificate
• Determine the target payer set and confirm which networks are open

Five Months Before

• Build and attest the CAQH ProView profile completely, including all documents and full work history
• Authorize all target payers to access the profile
• Submit the CMS-855B for the group through PECOS
• Submit the CMS-855I and CMS-855R together
• Initiate state Medicaid enrollment if Medicaid is material to the payer mix
• Stand up the credentialing tracking matrix

Four Months Before

• Submit commercial payer applications, ideally within two weeks of CAQH attestation
• Begin weekly status follow-up on every open application
• Respond to development requests within 48 hours

Three to Two Months Before

• Continue weekly follow-up and escalate any file with no movement in three weeks
• Review and negotiate contracts and fee schedules as approvals arrive
• Initiate Medicaid managed care plan credentialing once state enrollment completes
• Confirm the CAQH attestation date is not approaching

One Month Before and Through Opening

• Confirm effective dates in writing for each payer and load them into the practice management system
• Verify each provider is correctly linked to the group tax identification number in each payer’s system
• Establish the claim hold and release protocol for payers not yet effective
• Calendar all revalidation, recredentialing, and attestation dates

How DoctorsManagement Manages Credentialing End to End

DoctorsManagement maintains a dedicated credentialing team that manages provider enrollment from initial application through approval, contract execution, and ongoing maintenance. Credentialing is a discipline of persistence and detail, and it is poorly suited to being handled part-time by staff who also have other responsibilities.

Our credentialing services include:

• Full Enrollment Management: NPI registration, PECOS submission of the appropriate CMS-855 forms, state Medicaid enrollment, and commercial payer applications across your full target payer set
• CAQH Profile Management: Profile construction, document management, payer authorization, and ongoing 120-day attestation maintenance so nothing lapses
• Active Application Tracking: Systematic follow-up with each payer, rapid response to development requests, and escalation on stalled files, with regular status reporting to the practice
• Contract Review Support: Evaluation of participation agreements and fee schedules before execution, in coordination with our managed care team
• Ongoing Maintenance: Revalidation and recredentialing calendar management, change reporting, and roster maintenance as providers join and leave
• Startup Integration: Coordination of credentialing with the broader practice startup timeline so that enrollment runs in parallel with build-out rather than after it

If you are planning a practice or adding providers, contact DoctorsManagement at www.doctorsmanagement.com/credentialing or call (800) 635-4040. The most valuable thing we can do is start early, and that window closes daily.

Frequently Asked Questions

How long does provider credentialing take?

The full path from starting a credentialing file to holding an effective participation date is commonly 90 to 180 days per payer. Medicare through PECOS runs roughly 45 to 65 days for a clean electronic application. Commercial payer credentialing review typically runs 60 to 120 days after CAQH authorization, followed by two to six weeks for contract execution and system loading.

What is the difference between credentialing and enrollment?

Credentialing is verification of a clinician’s education, training, licensure, and history through primary source verification. Enrollment and contracting are the administrative registration and agreement execution that allow claims to be submitted and paid. A provider can be credentialed and still unable to bill because the contract is not executed or the record is not correctly linked.

Can I bill Medicare retroactively?

For initial CMS-855I individual enrollments, the effective date can be retroactive up to 30 days before CMS receives the signed application, and cannot precede the date the provider obtained all required credentials. For CMS-855B group enrollment, the effective date is generally the receipt date with no retroactivity. For CMS-855R reassignments, it is the later of the group’s effective date or the 855R receipt date.

What is CAQH ProView and why does the 120-day cycle matter?

CAQH ProView is the centralized credentialing data repository most commercial payers use. Providers must re-attest every 120 days whether or not anything changed. A lapsed attestation marks the profile inactive, which silently freezes every application in progress, stalls recredentialing, and can cause payers to drop directory listings or hold claims. Nothing alerts you when it happens.

Which CMS-855 form do I need?

Individual practitioners file the CMS-855I. Groups and organizations file the CMS-855B. Reassignment of billing rights to a group requires the CMS-855R. A physician forming or joining a group typically needs all three, and the 855R should be submitted alongside the 855I rather than after approval.

What changed with PECOS 2.0 in 2026?

The forms and five-year revalidation cycles are unchanged. New features include real-time validation during data entry, Stay of Enrollment, which freezes payment when validation finds a record discrepancy while the provider remains technically enrolled, and retroactive revocation authority effective January 1, 2026, under which CMS can revoke enrollment retroactively and recoup payments already made.

When should I start credentialing for a new practice?

Begin CAQH setup and primary source verification 120 or more days before the intended start date, and submit payer applications within about two weeks of CAQH attestation. For a new practice, this means starting roughly five to six months before opening, running in parallel with build-out. Entity formation and the EIN must come first, since the organizational NPI depends on them.

How much revenue does a credentialing delay actually cost?

Every week of delay is a week of full fixed operating cost incurred against zero corresponding revenue from the affected payers. For a solo practice projecting roughly $34,000 per month in eventual collections, a single month of avoidable delay represents that revenue deferred plus a month of rent, payroll, insurance, and debt service burned. This is why working capital should be sized for six to twelve months of operating expense.

Do I have to recredential after the initial process?

Yes. Medicare requires revalidation every five years for most provider types, and failure to respond results in deactivation and stopped payments. NCQA-accredited commercial plans must recredential at least every three years, with many payers on shorter cycles. CAQH attestation continues every 120 days throughout.

How can DoctorsManagement help with credentialing?

DoctorsManagement maintains a dedicated credentialing team handling full enrollment management across Medicare, Medicaid, and commercial payers, CAQH profile and attestation maintenance, active application tracking with escalation on stalled files, contract review support, and ongoing revalidation and recredentialing calendar management. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• NPPES National Plan and Provider Enumeration System
• Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
• CMS Medicare Provider Enrollment Resources (MLN9658742)
• CMS Provider and Supplier Enrollment
• CAQH ProView
• CAQH ProView Solution Overview
• NCQA Credentialing Standards
• URAC Credentials Verification Organization Accreditation
• CMS Regulations and Guidance
• DoctorsManagement Credentialing Services
• DoctorsManagement Practice Startup Services
• DoctorsManagement Accounting and Tax Services

Contact Us

This article is provided for informational and educational purposes only and does not constitute legal or financial advice. Credentialing and enrollment requirements, processing timelines, effective date rules, and application fees vary by payer, by state, and over time, and are subject to change. Practices should verify current requirements with each payer and consult qualified professionals regarding their specific circumstances. DoctorsManagement is available to manage provider credentialing and enrollment on behalf of practices.

The post Credentialing and Provider Enrollment: The Hidden Timeline That Can Make or Break Your New Practice appeared first on DoctorsManagement.

Introduction: Most Practices Track Numbers, Few Track the Right Ones

Ask a practice manager how the practice is performing and you will usually get a revenue figure. Ask how that figure compares to what the practice should be collecting given its charges, payer mix, and specialty, and the conversation changes.

This is the measurement gap that defines most medical practices. Revenue is an outcome. It tells you what happened. It does not tell you why, and it does not tell you what to do differently. A practice can post record collections in a quarter while its denial rate quietly climbs, its aged receivables build, and its provider schedule runs at a utilization level that predicts staff turnover within a year.

Key performance indicators exist to close that gap. A properly constructed KPI set functions as a diagnostic panel: each metric isolates one part of the operation, and the pattern across metrics points toward a cause. Days in accounts receivable climbing while denial rate holds steady is a follow-up problem. Both climbing together is an upstream problem in coding or eligibility. The same symptom means different things depending on what accompanies it.

Two failure modes are common. The first is tracking nothing systematically, reviewing financials once a year at tax time, and discovering problems long after they became expensive. The second is more subtle: tracking dozens of metrics on a dashboard nobody acts on, which produces the comfortable feeling of measurement without any of the benefit.

This guide is built as a working reference. Each KPI section gives you the formula, the benchmark range and its source, what the metric actually tells you, what typically causes it to drift, and what to do about it. The later sections cover how to benchmark without fooling yourself, how to structure a dashboard and review cadence people will actually use, and how to reason from a symptom to a root cause.

How to Use This Guide

You do not need to implement every metric here, and a practice that tries to will implement none of them well.

• If you track nothing today, start with the five metrics in the next section. They will surface the majority of correctable problems in a typical practice.
• If you already track financial metrics, use the operational sections to find the capacity and access problems that financial metrics cannot see.
• If a specific number looks wrong, go directly to that KPI section, then to the diagnostic pathways near the end of the guide.
• If you are preparing for a valuation, sale, or partnership discussion, work through the financial section completely. Sophisticated buyers examine these metrics closely, and they influence what a practice is worth.

A note on the benchmarks throughout. The figures cited reflect commonly published MGMA, HFMA, and industry survey ranges available at the time of writing. Benchmark data is updated annually, varies by specialty, practice size, and region, and different sources define some metrics differently. Treat the ranges here as orientation rather than as precise targets, and validate against current specialty-specific data before setting formal goals.

The Vital Few and the Diagnostic Many

Effective KPI programs are tiered. A small set of metrics gets reviewed constantly; a larger set gets consulted when the small set signals a problem.

Tier One: The Vital Few

Five metrics, reviewed monthly by practice leadership, catch most of what matters:

• Days in accounts receivable. How long it takes to get paid.
• Net collection rate. Whether you are collecting what you are entitled to collect.
• Denial rate. Where process failures are showing up.
• No-show rate. Whether capacity is being wasted.
• Overhead ratio. Whether the cost structure is sustainable.

Tier Two: The Diagnostic Many

Everything else in this guide. These are pulled when a Tier One metric moves, to isolate the cause. A rising denial rate sends you to denial-by-payer, denial-by-reason-code, first-pass resolution, and appeal overturn rate. You do not need those four on a monthly dashboard. You need to know they exist and where to find them.

Why Tiering Matters

A dashboard with thirty metrics gets scanned, not read. Attention is finite, and a metric that never triggers a decision is overhead. Keeping the standing review short is what makes it survive contact with a busy month.

Financial KPI: Days in Accounts Receivable

Formula

Total accounts receivable divided by average daily charges, where average daily charges equals total charges for the period divided by the number of days in the period. A rolling twelve-month basis smooths seasonal distortion.

Benchmark

• MGMA benchmark for most specialties: 30 to 40 days
• Top performers: under 30 days, with the strongest practices in the 25 to 30 range
• Warning threshold: above 50 days
• Serious concern: above 60 days

Published analysis indicates practices sustaining above 50 days in AR carry materially higher bad debt risk, on the order of 15 to 20 percent greater than practices holding within benchmark.

What It Tells You

Lag. This is the cleanest single measure of how efficiently the revenue cycle converts services into cash. It is also the metric most directly tied to whether the practice can meet payroll comfortably.

Common Causes of Drift

• Prior authorization delays pushing claims later in the cycle
• Denials that sit unworked because staff are absorbed reworking newer claims
• Underpayments nobody has time to appeal
• Aged AR untouched past 90 days
• Charge entry lag between date of service and claim submission
• Patient balances with no structured follow-up process

Improvement Actions

• Measure charge lag separately. If days from service to submission exceeds two to three days, the problem is upstream of the payer and entirely within your control.
• Establish a worked-queue discipline with defined touch intervals so no claim sits untouched past a set number of days.
• Prioritize the aging buckets by recoverability rather than by size, since older balances collect at sharply lower rates.
• Separate payer AR from patient AR in reporting. They behave differently and respond to different interventions.

Financial KPI: Accounts Receivable Aging Distribution

Formula

Percentage of total AR falling in each bucket: 0 to 30 days, 31 to 60, 61 to 90, 91 to 120, and over 120.

Benchmark

• More than half of total AR should sit in the 0 to 30 day bucket
• AR older than 90 days ideally stays under roughly 13 to 14 percent of the total
• Collection probability drops sharply once a claim passes 120 days, and many practices begin writing off around that point

Why This Matters More Than the Average

Days in AR is a single number and single numbers hide distributions. Two practices can both report 38 days while one has a healthy, evenly aging book and the other has most balances collecting quickly alongside a growing pile of stale claims that will never be collected. The average conceals the second practice’s problem until the write-offs arrive.

Review the distribution alongside the average every month. A stable average with a thickening 90-plus bucket is a deteriorating practice reporting a healthy number.

Improvement Actions

• Set a hard rule that nothing enters the 90-plus bucket without a documented reason and an assigned owner
• Run a one-time cleanup of legacy aged AR so ongoing measurement is not distorted by uncollectible history
• Track the 90-plus percentage as a trend line, since direction matters more than the absolute figure

Financial KPI: Net Collection Rate

Formula

Payments collected divided by the quantity of total charges minus contractual adjustments, expressed as a percentage. MGMA recommends a rolling twelve-month calculation to account for seasonal variation.

Benchmark

• MGMA recommends 95 percent or higher
• Top-performing practices: 95 to 98 percent
• Below 95 percent generally indicates recoverable revenue is being lost

Larger groups tend to outperform smaller practices here, largely because scale supports dedicated billing specialists, denial management staff, and more capable software.

What It Tells You

This is the single most important financial KPI in most practices. It answers whether you are actually collecting the money you were contractually entitled to collect, after accounting for the discounts you agreed to. Everything you failed to collect that you could have collected shows up here.

Common Causes of Drift

• Charge capture failures, meaning services rendered but never billed
• Coding that understates the level of service documented
• Timely filing misses
• Underpayments accepted without comparison to the contracted rate
• Denials written off rather than appealed
• Patient balances abandoned without a collection workflow

Improvement Actions

• Do not start with collections staff productivity. A weak net collection rate usually originates upstream. Examine charge capture, coding accuracy, payer rules, and patient balance workflow before concluding the billing team needs to work harder.
• Audit against contracted rates. Systematic underpayment is common and largely invisible unless someone compares remittances to the fee schedule. Practices frequently discover a payer has been paying below contract for months.
• Review coding accuracy independently. Undercoding depresses net collection rate just as surely as denials do, and it is often the larger number. An independent coding review quantifies it.
• Calculate on a rolling twelve months. Monthly snapshots swing on timing and produce false alarms and false comfort in roughly equal measure.

Financial KPI: Gross Collection Rate and Why It Misleads

Formula

Total payments divided by total charges, expressed as a percentage.

Why It Is Reported

It is easy to calculate and every practice management system produces it.

Why It Misleads

Gross collection rate is driven primarily by your fee schedule, not by your billing performance. A practice that raises its charges will see gross collection rate fall even if it collects exactly the same dollars from exactly the same claims. A practice with an aggressive fee schedule will always look worse on this metric than a practice with conservative charges, regardless of which one runs a better revenue cycle.

Because contractual adjustments are not removed, the metric mostly measures the gap between what you charge and what payers have agreed to pay, which is a contracting question rather than an operational one.

How to Use It

Track it for trend within your own practice, where a sudden change may indicate a fee schedule update or payer mix shift. Do not use it to compare against other practices, and do not use it as a proxy for billing performance. Net collection rate is the operational measure.

Financial KPI: Denial Rate

Formula

Claims denied divided by total claims submitted, expressed as a percentage, measured over a consistent period.

Benchmark

• MGMA benchmark data points to approximately 8 percent, with lower being better
• Top-quartile practices hold below 5 percent
• Broader industry average runs closer to 8 to 10 percent, and some analyses report 10 to 15 percent
• The American Hospital Association reported average initial denial rates rising to 11.8 percent in 2024

The Critical Refinement

A blended denial rate hides more than it reveals. An overall rate of 4 percent looks excellent and can conceal one payer denying 15 percent of your claims while others sit under 2 percent. The blended number tells you the practice is fine. The payer-level breakdown tells you which relationship needs attention.

Break denials down two ways at minimum:

• By payer. Isolates payer-specific policy problems, prior authorization requirements your team has not absorbed, and contract interpretation disputes.
• By reason code. Denials cluster around eligibility errors, missing authorizations, coding mismatches, and timely filing misses. Each cluster has a different owner and a different fix.

Improvement Actions

• Verify eligibility before every visit, not at check-in. Eligibility failures are the most preventable denial category.
• Build payer-specific prior authorization requirements into scheduling workflow rather than relying on staff memory.
• Route coding-mismatch denials back to a coding review rather than treating them as billing problems.
• Track denial rate as a monthly trend by payer, and open a conversation with any payer whose rate diverges materially from the others.

Financial KPI: First-Pass Resolution and Clean Claim Rate

Formula

Claims accepted and paid on first submission, without rejection, denial, or correction, divided by total claims submitted.

Benchmark

• Industry average hovers around 95 percent
• The benchmark to hold in 2026 is 97 percent or higher
• Practices with mature rules engines and strong front-end processes approach 99 percent
• Below 95 percent indicates upstream problems, typically coding errors, missing modifiers, or documentation that does not support the diagnosis billed

Why the Arithmetic Is Worse Than It Looks

Ninety-five percent sounds unobjectionable until it is converted into work. A practice submitting 1,000 claims monthly at a 95 percent first-pass rate generates 50 claims requiring manual rework every single billing cycle. That is staff time, delayed payment, and a share of those claims that will eventually be written off because rework never happened.

Moving from 95 to 98 percent cuts that rework queue by more than half, which is usually worth more than the direct revenue effect because it frees the billing team to work denials and aged AR instead.

Improvement Actions

• Treat first-pass rate as a front-end metric. The fix is almost never in the billing office.
• Use claim scrubbing that evaluates coding accuracy, bundling edits, and modifier appropriateness before submission.
• Analyze rejections separately from denials, since rejections indicate data and format problems while denials indicate policy and documentation problems.

Financial KPI: Appeal Overturn Rate

Formula

Appealed denials overturned in the practice’s favor divided by total denials appealed.

How to Read It

This metric is counterintuitive, because a high number is not straightforwardly good news.

An appeal overturn rate above 50 percent suggests many of those denials were preventable in the first place. If more than half of what you contest gets reversed, the denials were largely improper or resulted from correctable submission errors, and the practice is spending staff time recovering money it should never have had to chase.

A very low overturn rate suggests the opposite problem: either the denials are legitimate and the underlying documentation or coding is genuinely deficient, or the appeals themselves are being submitted without adequate support.

Improvement Actions

• Where overturn rates are high, trace the reversed denials back to root cause and fix the submission process rather than celebrating the recovery
• Where overturn rates are low, audit a sample of denied claims independently to determine whether the denials are correct
• Track appeal cycle time alongside overturn rate, since recovered revenue arriving twelve months late has meaningfully less value

Financial KPI: Cost to Collect

Formula

Total revenue cycle cost divided by total collections, expressed as a percentage. Revenue cycle cost includes billing and coding staff compensation and benefits, outsourced billing fees, clearinghouse and software costs, and an allocation of management time.

Benchmark

Industry benchmarks commonly estimate billing and revenue cycle costs at roughly 5 percent of collections. Outsourced arrangements typically run in the 5 to 8 percent range depending on scope and specialty.

What It Tells You

What each dollar of revenue costs to capture. It is also the metric that frames the in-house versus outsourced billing decision honestly, because practices comparing an outsourcing quote against in-house costs frequently omit software, clearinghouse fees, benefits, and management time from the internal number and conclude in-house is cheaper than it is.

The Interaction Worth Watching

Cost to collect should never be evaluated alone. Cutting revenue cycle staff lowers cost to collect and will often raise days in AR and lower net collection rate at the same time, producing a worse outcome that looks like an efficiency gain on a single metric. Review it against net collection rate and days in AR together.

Financial KPI: Point-of-Service and Patient Collection Rate

Formula

Patient payments collected divided by total patient responsibility. Point-of-service collection rate measures the portion collected at or before the visit.

Benchmark and Context

Patient collection performance has deteriorated industry-wide as deductibles have risen. Reported commercially insured patient collection rates have fallen to roughly 34 to 48 percent, and collection on balances above $7,500 can drop as low as 17 percent.

Why This Metric Is Growing in Importance

As patient responsibility grows as a share of total revenue, the practice’s ability to collect from patients increasingly determines its net collection rate. A practice with excellent payer collections and no patient collection process is losing a growing share of its revenue.

Improvement Actions

• Collect at or before the point of service. The probability of collection falls steeply once the patient leaves the office, and further with each statement cycle.
• Verify eligibility and estimate patient responsibility before the visit so the amount can be discussed rather than discovered
• Offer digital payment options and stored payment methods, which consistently outperform statement-driven collection
• Establish structured payment plans for larger balances rather than allowing them to age
• Write a financial policy, communicate it before the visit, and apply it consistently

Financial KPI: Overhead Ratio

Formula

Total practice operating expenses divided by total revenue, expressed as a percentage. Physician compensation is typically excluded in physician-owned practices, since it is the residual rather than an operating cost, but the treatment must be consistent to compare periods or benchmarks.

Benchmark

Overhead benchmarks vary widely by specialty and are among the least transferable figures in this guide. Procedural specialties with significant equipment and supply costs run structurally different overhead than cognitive specialties. Compare only against your own specialty, and confirm how the benchmark source treats physician compensation before drawing conclusions.

Cost Structure Context

Labor dominates the expense structure in most practices. Support staff salaries and benefits alone typically account for roughly a quarter of total practice revenue. When physician and advanced practice provider compensation is included, total labor commonly consumes 50 to 60 percent or more of all operating expenditures.

Cost pressure has been broad-based. In a June 2025 MGMA Stat poll, 90 percent of medical groups reported year-to-date operating costs higher than at the same point in 2024, with only 3 percent reporting a decrease.

Improvement Actions

• Decompose overhead into labor, occupancy, clinical supplies, technology, insurance, and administrative categories before attempting to act on it
• Evaluate overhead as a trend against revenue growth, since a rising ratio during a growth period may reflect appropriate investment rather than inefficiency
• Benchmark staffing levels per FTE provider against specialty data before concluding the practice is overstaffed or understaffed

Financial KPI: Revenue per Encounter and per Provider

Formulas

Revenue per encounter equals payments divided by total encounters for the same period. Revenue per provider equals collections attributable to a provider divided by that provider’s clinical FTE.

What They Tell You

Revenue per encounter isolates yield per visit, which makes it useful for detecting coding drift, payer mix shifts, and service mix changes that volume-based metrics obscure. A practice with flat revenue and rising encounter volume has a declining revenue per encounter and a problem worth investigating.

Revenue per provider supports compensation modeling and identifies performance variation within a group. Interpret it carefully, since providers with different case mixes, panel compositions, and administrative responsibilities are not directly comparable.

Improvement Actions

• Track revenue per encounter by provider and by payer to separate coding variation from payer mix effects
• Where revenue per encounter declines without a payer mix explanation, commission a coding review, since undercoding is a frequent and correctable cause
• Use provider-level variation as a prompt for inquiry rather than as a performance verdict

Operational KPI: No-Show and Cancellation Rate

Formula

No-shows divided by total scheduled appointments. Track same-day cancellations separately, since they behave differently and respond to different interventions.

Benchmark

MGMA benchmarking for well-managed practices points to a target range of roughly 5 to 8 percent.

The Financial Weight

Individual missed appointments are commonly estimated near $150 to $200 each once lost revenue, wasted staff preparation time, and idle room capacity are combined. A practice running a 10 percent no-show rate on moderate patient volume can lose well into six figures annually.

This is the metric where the gap between perceived and actual cost is widest. Practices tolerate a no-show rate they would never tolerate as an equivalent line item on the expense statement.

Improvement Actions

• Automate multi-channel reminders with confirmation capability, timed at intervals that allow the slot to be refilled.
• Maintain an active waitlist so cancelled slots can be filled same-day rather than lost.
• Analyze no-shows by segment. Rates typically vary by appointment type, day of week, time of day, lead time from booking, and payer. The intervention should follow the pattern.
• Reduce booking lead time where possible, since no-show probability rises with the interval between scheduling and appointment.
• Apply a policy consistently if the practice adopts one, since inconsistent enforcement produces the administrative burden without the behavioral effect.

Operational KPI: Provider Utilization

Formula

Care hours delivered divided by total available scheduled hours, expressed as a percentage.

Benchmark

• Target range: 70 to 85 percent
• Sustained utilization above 90 percent correlates with higher staff turnover and rising error rates

The Metric With a Ceiling

This is one of the few KPIs where higher is not better. A practice running providers at 95 percent utilization has no absorptive capacity for a complex patient, a late arrival, or an urgent add-on, which means every disruption cascades through the day. The measurable consequences appear in turnover and errors rather than in the utilization figure itself.

Utilization should never be reviewed in isolation from denial rate and patient experience metrics. A practice that improved utilization while degrading both has traded durable performance for short-term throughput.

Improvement Actions

• Build deliberate buffer capacity into the template rather than relying on cancellations to create it
• Where utilization runs low, examine scheduling template design, referral flow, and access before adding marketing spend
• Where utilization runs high, treat it as a capacity signal and evaluate provider recruitment or extended hours rather than compressing the schedule further

Operational KPI: Cycle Time and Patient Throughput

Formulas

Cycle time is the total elapsed time from patient check-in to check-out. Throughput is patients seen per provider hour. Wait time is the interval from scheduled appointment time to provider contact.

Benchmark

• Cycle time target: under 60 minutes total in most outpatient specialties
• Primary care throughput: roughly 4 to 6 patients per hour per provider
• Ophthalmology: roughly 6 to 10 patients per hour, depending on technician support

Throughput benchmarks are highly specialty-dependent and should be sourced specifically. The broader point is that benchmarks distinguish normal variation from genuine underperformance, which is difficult to judge from inside the practice.

Measuring It Properly

Segment the visit rather than measuring only the total. Check-in to rooming, rooming to provider, provider time, and check-out each have distinct owners and distinct fixes. A 75-minute cycle time caused by a 30-minute wait in the lobby is a scheduling and front-desk problem. The same cycle time caused by a 30-minute wait in the exam room after rooming is a provider workflow problem.

Improvement Actions

• Map each phase with time, task ownership, and process efficiency documented
• Use standing morning huddles to align staff and surface anticipated bottlenecks before they occur
• Interview frontline staff, who routinely identify workflow issues that raw data does not surface
• Address the largest single segment first rather than attempting to compress the whole visit

DoctorsManagement has published a detailed treatment of this analysis in How to Analyze Patient Throughput and Clinic Flow.

Operational KPI: Third Next Available Appointment

Formula

The number of days until the third available new patient appointment slot.

Why the Third and Not the First

The first and second available slots are frequently the product of recent cancellations and therefore misrepresent true access. The third available is the standard access measure precisely because it is harder for chance openings to distort.

What It Tells You

Real appointment availability from a patient’s perspective. It is a leading indicator for new patient volume, referral relationships, and patient satisfaction. Referring physicians route patients to practices that can see them, and extended access delays quietly erode referral flow before the volume decline appears in financial reporting.

Improvement Actions

• Measure separately for new and established patients, and by provider
• Evaluate template design, including the proportion of slots held for new patients
• Address no-show rate, since reducing waste creates access without adding capacity
• Consider whether the constraint is provider hours, room availability, or support staffing, since each has a different remedy

Operational KPI: Staffing Ratio and Support Staff Cost

Formulas

Support staff FTEs per physician FTE. Support staff cost as a percentage of total revenue.

Benchmark Context

Support staff salaries and benefits typically account for roughly a quarter of total practice revenue. Appropriate FTE ratios vary substantially by specialty, care model, and the degree to which functions such as billing are outsourced, so specialty-specific benchmarks are essential here.

Interpreting It Carefully

Staffing ratios are among the most commonly misused benchmarks. A practice below the benchmark ratio may be efficient or may be understaffed in a way that is suppressing collections, access, and patient experience simultaneously. A practice above the benchmark may be inefficient or may be running an in-house function that peers outsource.

MGMA data has shown that physician-owned practices excluding primary care have reported lower total expenses largely due to leaner staffing, while primary care practices increased staffing levels and saw overall costs rise. Neither pattern is inherently correct; they reflect different care models.

Improvement Actions

• Normalize for outsourced functions before comparing to any benchmark
• Evaluate staffing against output metrics rather than in isolation, since understaffing typically shows up first in days in AR and access rather than in the staffing ratio
• Examine role allocation as well as headcount, since practices are frequently correctly staffed in total and incorrectly distributed across functions

Clinical and Experience KPIs

Clinical and experience metrics vary far more by specialty and by payer program participation than financial and operational metrics, so this section describes categories rather than universal benchmarks.

Preventive Care and Quality Measure Compliance

Rates of completion for age and condition-appropriate screening, immunization, and chronic disease management measures. These increasingly carry direct financial consequence through value-based contracts, quality bonus arrangements, and federal quality program scoring. Track the specific measures your contracts actually reward rather than a generic panel.

Patient Satisfaction and Experience

Collected through post-visit surveys, standardized instruments, or net promoter scoring. Research consistently associates positive patient experience with better adherence and stronger patient loyalty.

The operational value comes from segmentation. An aggregate satisfaction score is nearly useless for improvement; the same data broken down by provider, by visit type, and by experience dimension such as wait time, communication, or billing clarity points to specific action.

Online Reputation

Review volume, average rating, and response rate across major platforms. For most practices this now functions as a patient acquisition metric rather than a purely reputational one, since prospective patients consult reviews before scheduling. Review velocity matters as much as average rating, since a strong average built on stale reviews carries less weight.

Patient Retention

The proportion of established patients returning within an expected interval for their condition and specialty. Retention erosion is a leading indicator that typically precedes visible volume decline by several quarters, which makes it valuable despite being harder to measure cleanly.

Benchmarking Correctly: Where Comparisons Break Down

Benchmarks are useful and they are also the source of a great deal of misdirected effort. Four cautions matter.

Specialty Specificity

Overhead ratios, staffing ratios, throughput, and revenue per encounter differ enormously across specialties. A blended multi-specialty benchmark is nearly meaningless for a single-specialty practice. Always source specialty-specific data where the metric is specialty-sensitive.

Practice Size

Larger groups consistently outperform smaller practices on revenue cycle metrics, because scale supports specialized billing teams, dedicated denial management staff, and more sophisticated software. A five-physician practice measuring itself against twenty-provider group benchmarks will conclude it is failing when it may be performing well for its size.

Definitional Variation

Sources define metrics differently. Some calculate days in AR on gross charges and others on net. Some include patient AR and others separate it. Some overhead benchmarks include physician compensation and others exclude it. A comparison across inconsistent definitions produces a number that means nothing. Confirm the definition before drawing a conclusion from any benchmark.

Benchmarks Are a Floor, Not a Goal

Meeting the median means performing at the middle of a distribution that includes a substantial number of poorly run practices. Benchmarks establish whether a metric is aberrant. Internal targets, set against the practice’s own trend and circumstances, are what actually drive improvement.

Building the Dashboard and Setting the Review Cadence

The Cadence

• Weekly: Charge lag, claim submission volume, denial volume, and schedule fill rate. Operational metrics that support immediate correction.
• Monthly: The Tier One five, plus AR aging distribution, first-pass rate, and revenue per encounter. Reviewed by practice leadership together.
• Quarterly: Overhead detail, staffing ratios, provider-level performance, payer-level analysis, and access metrics.
• Annually: Full benchmark comparison against refreshed specialty data, payer contract performance review, and goal reset.

Visual Design

A green zone and red zone approach translates numbers into signals and makes a dashboard scannable in seconds. If days in AR exceeds a defined threshold, the box turns red and the metric enters the meeting agenda automatically rather than depending on someone noticing.

Set thresholds in advance, in writing. Thresholds established after a bad month tend to be set where the bad month lands.

Ownership

Dashboards work best when owned by practice leadership rather than delegated entirely to accounting. The goal is engagement and decision-making, not reporting. When physicians and managers review the same dashboard monthly, financial performance becomes a shared responsibility rather than something discovered after the fact.

Assign every Tier One metric a named owner accountable for explaining movement and proposing action. A metric that belongs to everyone belongs to no one.

Meeting Structure

A consistent structure keeps the review short and productive: metrics, then exceptions, then root cause discussion, then action items with owners and dates. Fifteen to thirty focused minutes monthly outperforms an hour of unstructured review, and it survives busy months, which is the real test.

DoctorsManagement’s framework for this discipline is developed further in Beyond Profitability: A Practical Framework for Assessing the Financial Health of Your Medical Practice.

When a Metric Is Off: Diagnostic Pathways

The value of a KPI set is in the pattern, not the individual number. These pathways move from symptom to likely cause.

Days in AR Rising

First check whether denial rate is also rising. If both are rising, the problem is upstream in eligibility, coding, or documentation, and fixing collections workflow will not resolve it. If denial rate is stable and days in AR is rising, the problem is in follow-up capacity or aged AR management. Then check charge lag, because a submission delay presents identically to a payment delay in this metric.

Net Collection Rate Falling

Check denial rate, timely filing performance, and contracted rate variance in that order. If none explain the gap, the likely cause is charge capture or undercoding, both of which require an independent coding review to quantify. Confirm the calculation is on a rolling twelve-month basis before treating a single month’s decline as real.

Denial Rate Rising

Break down by payer immediately. A single payer driving the increase points to a policy change, a prior authorization requirement, or a contract interpretation dispute. Denials distributed across payers point to an internal process failure. Then break down by reason code to identify the specific failure point.

Revenue Flat While Volume Grows

Revenue per encounter is declining. Determine whether the cause is payer mix shift, service mix shift, or coding drift. Coding drift is the most common and the most correctable, and it requires an independent review because internal coders rarely identify their own systematic patterns.

Utilization High but Revenue Flat

Providers are busy and the practice is not capturing the value. Examine charge capture first, then coding accuracy, then whether the visit mix has shifted toward lower-yield encounter types. High utilization with flat revenue is one of the more reliable indicators of a charge capture failure.

Overhead Rising Faster Than Revenue

Decompose into categories before acting. Rising labor cost during a growth phase may be appropriate investment. Rising labor cost during flat revenue is a staffing or productivity issue. Rising occupancy or technology cost is usually contractual and requires a different remedy entirely.

Common Measurement Mistakes

• Tracking too many metrics. A thirty-metric dashboard gets scanned rather than read. Tier the set and keep the standing review short.
• Reviewing metrics without acting on them. A metric that has never changed a decision is administrative overhead. Either attach it to an action threshold or remove it.
• Using gross collection rate as a performance measure. It measures your fee schedule more than your billing operation.
• Relying on blended rates. Blended denial rates hide payer-specific problems. Blended satisfaction scores hide provider-specific problems. Segment before concluding.
• Comparing against mismatched benchmarks. Wrong specialty, wrong practice size, or a different metric definition produces a comparison that means nothing.
• Optimizing one metric in isolation. Cutting revenue cycle staff improves cost to collect and damages days in AR and net collection rate. Review interacting metrics together.
• Measuring monthly what should be measured on a rolling basis. Net collection rate in particular swings on timing and produces false signals month to month.
• Treating the average as the whole story. Days in AR without the aging distribution, and utilization without patient experience, both conceal deterioration.
• Assigning no owner. Metrics without a named owner do not get explained or acted upon.
• Setting thresholds after the fact. Thresholds defined in advance are targets. Thresholds defined after a bad month are rationalizations.

How DoctorsManagement Turns Metrics Into a Roadmap

Benchmarking tells you that a number is off. It does not tell you why, and it does not tell you what to do about it. That distinction is where most KPI programs stall: the practice knows days in AR is 54 against a benchmark of 35 and has no reliable way to determine which of a dozen possible causes is responsible.

The DoctorsManagement Medical Practice Assessment is built for exactly that gap. It is a structured, data-driven evaluation of the core systems that collectively drive practice performance. Unlike a benchmarking exercise or a surface-level review, it focuses on identifying root causes, quantifying the opportunity, and translating findings into a prioritized, practical roadmap for measurable improvement.

Our consulting and accounting teams work together on what we describe as keeping score: proactive monthly recording of where the practice has been, where it stands, and where it intends to go.

Services relevant to practice performance measurement include:

• Medical Practice Assessment: Comprehensive evaluation across revenue cycle, patient flow, staffing, technology, and financial performance, producing a prioritized improvement roadmap rather than a report of findings
• Financial Reporting and Monthly Management Reports: Custom reporting built on profit center data that depicts cash flow for specific areas of the practice, enabling decisions rather than merely documenting results
• Revenue Cycle Analysis: Diagnostic review of days in AR, denial patterns by payer and reason code, net collection performance, and underpayment identification
• Coding and Documentation Review: Independent quantification of coding accuracy, which is the most common unmeasured driver of net collection rate and revenue per encounter
• Patient Throughput and Clinic Flow Analysis: Segment-level evaluation of cycle time and capacity utilization, including staff interviews that surface workflow issues the data does not show
• Accounting and Practice Management Consulting: Ongoing financial management and operational guidance across the practice lifecycle

To discuss where your practice stands and what a structured assessment would surface, visit www.doctorsmanagement.com/practice-assessment or call (800) 635-4040 to schedule a discovery call.

Frequently Asked Questions

What are the most important KPIs for a medical practice?

Five metrics catch most correctable problems: days in accounts receivable, net collection rate, denial rate, no-show rate, and overhead ratio. If your practice tracks nothing systematically today, start there and review them monthly with leadership. Everything else in this guide functions as diagnostic depth pulled when one of those five moves.

What is a good days in AR for a medical practice?

MGMA benchmarks for most specialties fall in the 30 to 40 day range, with top performers under 30 and the strongest practices between 25 and 30. Above 50 days is a warning sign and is associated with materially higher bad debt risk. Review the aging distribution alongside the average, since a healthy average can conceal a growing pile of stale claims.

What is the difference between gross and net collection rate?

Gross collection rate is payments divided by charges, which is driven mainly by your fee schedule rather than your billing performance. Net collection rate is payments divided by charges minus contractual adjustments, which measures whether you collected what you were actually entitled to collect. Net collection rate is the operational measure; gross is useful only for internal trend.

What denial rate should my practice target?

MGMA benchmark data points to approximately 8 percent with lower being better, and top-quartile practices hold below 5 percent. More important than the overall figure is the breakdown by payer and by reason code. A blended rate of 4 percent can conceal one payer denying 15 percent of your claims.

How much does a no-show actually cost?

Individual missed appointments are commonly estimated near $150 to $200 each once lost revenue, wasted staff preparation, and idle room capacity are combined. A practice running 10 percent no-shows on moderate volume can lose well into six figures per year. MGMA benchmarking for well-managed practices targets 5 to 8 percent.

Can provider utilization be too high?

Yes, and this is one of the few KPIs with a ceiling. The target range is 70 to 85 percent. Utilization sustained above 90 percent correlates with higher staff turnover and rising error rates, because the schedule has no absorptive capacity for complex patients, late arrivals, or urgent add-ons. Never review utilization without also reviewing denial rate and patient experience.

How often should we review KPIs?

Weekly for operational metrics supporting immediate correction, monthly for the core five with leadership present, quarterly for staffing, overhead detail, and provider-level analysis, and annually for full benchmark comparison and goal reset. Fifteen to thirty focused minutes monthly, with a consistent structure and named owners, outperforms longer unstructured reviews.

Where do I find reliable benchmark data?

MGMA DataDive is the most widely referenced source for physician practice benchmarking, with HFMA and specialty society data also useful. Confirm the metric definition, specialty, and practice size cohort before comparing, since sources define several of these metrics differently and a mismatched comparison produces a meaningless result.

Our numbers look fine but the practice feels strained. What are we missing?

Usually operational metrics, which financial reporting cannot see. Check provider utilization, cycle time by visit segment, third next available appointment, and staffing ratios. A practice can post acceptable financial results while running providers at unsustainable utilization and losing referral flow to access delays, both of which appear in financial reporting only after they have persisted for several quarters.

How can DoctorsManagement help us improve our metrics?

Our Medical Practice Assessment is a structured, data-driven evaluation of the systems that drive performance, focused on identifying root causes, quantifying opportunity, and producing a prioritized improvement roadmap. We also provide monthly management reporting, revenue cycle analysis, independent coding review, and patient throughput analysis. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• Medical Group Management Association (MGMA)
• MGMA Stat: Medical Practice Operating Costs Are Still Rising
• American Medical Association Private Practice Resources
• DoctorsManagement Medical Practice Assessment
• Beyond Profitability: Assessing the Financial Health of Your Medical Practice
• Steps in a Healthcare Financial Analysis
• How to Analyze Patient Throughput and Clinic Flow
• 5 Common Revenue Cycle Management Mistakes That Hurt Your Bottom Line
• Essential Steps to Improve Operational Efficiency in a Healthcare Practice
• Medical Practice Valuation: How to Estimate Your Selling Value
• DoctorsManagement Coding and Documentation Review
• DoctorsManagement Accounting Services

Contact Us

This article is provided for informational and educational purposes only and does not constitute financial, legal, or tax advice. Benchmark figures cited reflect commonly published industry ranges available at the time of writing. Benchmark data is updated periodically, varies by specialty, practice size, and geographic region, and different sources define several of these metrics differently. Practices should validate against current specialty-specific data before setting formal performance targets. DoctorsManagement is available to provide practice assessment, financial reporting, and management consulting services.

The post Medical Practice KPIs That Matter: A Data-Driven Guide to Measuring and Improving Performance appeared first on DoctorsManagement.

Introduction: The Moment a Billing Error Becomes a Legal Obligation

A coder flags a pattern during a routine internal review. A payer remittance shows a duplicate payment. A departing biller mentions that a particular code has been submitted incorrectly for months. An external audit returns findings on a sample of thirty claims.

In each case the practice has just crossed a line, and most practices do not recognize it at the time. What began as a billing question has become a federal legal obligation with a running deadline, and the consequences of mishandling the next sixty days are considerably more serious than the underlying error.

The obligation comes from what is commonly called the 60-Day Rule. A provider who receives Medicare or Medicaid funds to which it is not entitled must report and return those funds within 60 days of identifying the overpayment. Failure to do so does not simply leave the original error in place. It converts retention of the money into an independent violation of the False Claims Act, with treble damages and per-claim penalties attaching to conduct that had nothing to do with how the claim was originally submitted.

This is the mechanism by which an honest coding mistake becomes an enforcement matter. The original error may have been entirely inadvertent and carry no FCA exposure at all. Keeping the money after you knew about it is a separate act, and the government treats it as one.

The rule changed materially on January 1, 2025, and a great deal of the guidance practices are still operating from is now wrong. CMS replaced the standard for when an overpayment is considered identified, removed the requirement that the amount be quantified before the clock starts, and codified a defined investigation window. Practices working from the pre-2025 mental model, in which the deadline did not begin until an investigation had confirmed and calculated the overpayment, are exposed in a way they do not realize.

This guide covers what the rule requires, precisely what changed, how the new identification standard works in practice, when the deadline can legitimately be suspended, how far back the obligation reaches, how audit findings create obligations for claims no auditor ever reviewed, and how to build an internal protocol that handles all of this without improvisation.

The Statutory Framework

The obligation originates in Section 6402 of the Affordable Care Act, which added Section 1128J(d) to the Social Security Act, codified at 42 U.S.C. 1320a-7k(d). It requires a person who has received an overpayment to report and return it by the later of two dates: 60 days after the overpayment is identified, or the date any corresponding cost report is due, if applicable.

CMS implemented the statute through regulation in stages. A 2014 final rule addressed Medicare Advantage organizations and Part D prescription drug plan sponsors. A 2016 final rule, published at 81 FR 7683 on February 12, 2016, addressed Medicare Part A providers and Part B suppliers and is codified at 42 CFR 401.301 through 401.305. That framework was substantially amended effective January 1, 2025.

Who It Applies To

Providers, suppliers, Medicare Advantage organizations, and Part D plan sponsors. For a physician practice, this means essentially any entity billing Medicare or Medicaid, regardless of size or specialty.

The Cost Report Element

The alternative deadline tied to a corresponding cost report applies only to entities that file cost reports. CMS has clarified that applicable reconciliation is limited to cost report reconciliation, meaning the circumstance where a provider receives cost-based interim payments and reconciles them against actual reimbursable costs when the cost report comes due. For a typical physician practice, this branch of the deadline is not in play, and the operative deadline is 60 days after identification.

What Counts as an Overpayment

An overpayment is any funds received or retained under Medicare or Medicaid to which the person is not entitled after applicable reconciliation.

No amount is too small. The regulation contains no de minimis threshold. This surprises practices that assume small-dollar errors are administratively excused, and it is a meaningful part of why an identification-and-refund protocol matters more than case-by-case judgment.

Common sources in physician practices include:

• Coding errors, including services billed at a level the documentation does not support
• Billing for services not rendered or not documented
• Duplicate submissions and duplicate payments
• Credit balances arising from payer and patient payment overlap
• Services billed under the wrong provider, including claims billed under a provider not properly enrolled or reassigned
• Claims that failed to meet coverage or medical necessity criteria under the applicable determination
• Services rendered during a period when the provider was not credentialed or the enrollment was inactive
• Claims tainted by an underlying legal violation, including arrangements that do not satisfy Anti-Kickback Statute safe harbors or Stark Law exceptions
• Payments received after a payer has already paid, where coordination of benefits was misapplied

A Note on Credit Balances

Credit balances sitting unresolved on the practice’s aged report are overpayments the practice has already identified in any practical sense. Practices frequently carry these for months or years as an accounting nuisance rather than recognizing them as retained federal funds. This is among the most common and most easily corrected exposures in the entire rule.

What Changed on January 1, 2025

CMS finalized revisions to the overpayment regulations as part of the CY 2025 Medicare Physician Fee Schedule Final Rule, published in the Federal Register on December 9, 2024 and effective January 1, 2025. The amendment appears in the regulatory history of 42 CFR 401.305 at 89 FR 98553.

Two changes carry practical consequence:

• The definition of identified changed. The prior reasonable diligence standard was replaced with the False Claims Act definition of knowingly, meaning actual knowledge, reckless disregard, or deliberate ignorance.
• The quantification construct was removed. Under the prior framework, the clock did not start until the provider had both confirmed the overpayment and calculated its amount. That linkage is gone.

CMS also codified a defined suspension period for good faith investigation of related overpayments, which is discussed in its own section below.

The net effect is that the clock now starts earlier, on a standard borrowed from fraud law, and starts whether or not the practice yet knows how much money is involved.

The Old Standard: Reasonable Diligence and Quantification

Under the 2016 rule, an overpayment was identified when the provider had, or should have had through the exercise of reasonable diligence, determined that it received an overpayment and quantified the amount.

This produced a two-step sequence that practices found workable. Information surfaced. The practice conducted a reasonably diligent investigation, generally understood as taking up to six months absent extraordinary circumstances. When that investigation confirmed the overpayment and calculated its amount, the 60-day clock began.

The practical consequence was that a practice had roughly eight months from the first indication of a problem to the refund deadline. Many internal compliance protocols were built around exactly that assumption, and a fair number of them have not been updated.

The New Standard: The False Claims Act Definition of Knowingly

Effective January 1, 2025, an overpayment is identified when the person has knowledge of it within the meaning of the False Claims Act. That standard has three prongs:

• Actual knowledge that an overpayment was received
• Reckless disregard of the truth or falsity of information indicating an overpayment
• Deliberate ignorance of that information

CMS pointed providers to the existing body of False Claims Act case law for interpretation and characterized the question of whether a person has the requisite knowledge as a fact-specific inquiry.

The Duty to Investigate

The framing has inverted in a way that matters. The operative question is no longer whether there is credible evidence sufficient to justify an investigation. It is whether failing to investigate would itself constitute reckless disregard or deliberate ignorance under the FCA. If it would, the practice must investigate.

This is a genuinely different posture. Under the old standard, a practice receiving an ambiguous signal had latitude to weigh whether it warranted inquiry. Under the new standard, that ambiguous signal may itself create a duty, and choosing not to look becomes the thing that establishes knowledge.

The Protection Inside the Standard

There is an important counterweight. So long as the practice is actively investigating a potential overpayment, it has not yet knowingly identified one. Active, documented investigation is what distinguishes a practice working the problem from a practice ignoring it, and it is the difference between the two prongs of the standard.

CMS has also addressed the timing where the culpable state of mind is not actual knowledge. Where a provider acts in deliberate ignorance or reckless disregard, the 60-day period begins on the date the provider so acted, rather than on some later date of eventual acknowledgment. A practice cannot improve its position by delaying the moment it admits what it already had reason to know.

Why the Court Decision Behind the Change Matters

The revision did not originate in a desire to make life harder for providers. CMS stated that the update was intended to provide consistency across Medicare overpayment regulations in response to a federal district court decision addressing the Medicare Part C overpayment rule. That court held that the reasonable diligence standard impermissibly established False Claims Act liability for what amounted to mere negligence.

The logic is worth understanding because it cuts in providers’ favor on one axis. Reasonable diligence is an objective negligence standard: you should have known. The FCA scienter standard requires something more culpable than carelessness. In that narrow sense, the new standard is harder for the government to satisfy.

The trade is that the standard now attaches much earlier in the timeline and without the quantification safe harbor. A practice gains a marginally higher bar on culpability and loses several months of runway. For most practices the second effect dominates.

The Quantification Problem CMS Created

This is the most operationally awkward feature of the revised rule. The 60-day period runs from identification even if the practice has not yet calculated the precise amount of the overpayment.

CMS acknowledged the obvious tension. A practice cannot return an indefinite sum. As a practical matter, therefore, the amount must be calculated within the same 60 days in order to meet the deadline. What was previously a sequential process, investigate and quantify first and then run a 60-day return clock, is now a compressed parallel process in which investigation, quantification, and refund all have to fit inside the same window.

What This Means for Practice Operations

Sixty days is not a long time to scope a billing issue across multiple providers and years of claims, extract and validate the data, calculate the refund, prepare the submission, and execute it. Practices that have never done this before routinely discover that data extraction alone consumes several weeks.

The implication is that the internal protocol has to exist before it is needed. A practice designing its response process after identification has already spent part of its window on design.

Where the Suspension Provisions Become Essential

Given the compression, the suspension provisions described in the next two sections are not technicalities. They are the mechanism by which a practice facing a genuinely complex overpayment obtains the time to handle it properly, and knowing how to use them is a core competency for anyone managing this process.

When the 60-Day Deadline Can Be Suspended

The regulation provides for suspension of the deadline in defined circumstances. These are the practice’s principal tools when the sixty days are not workable.

Disclosure Under the OIG Self-Disclosure Protocol

The deadline is suspended once the OIG acknowledges receipt of a Self-Disclosure Protocol submission. Suspension continues for the duration of settlement negotiations. When negotiations conclude, or the provider is no longer actively engaged in the process, the suspension ends and the return obligation resumes.

Disclosure Under the CMS Voluntary Self-Referral Disclosure Protocol

The same structure applies to the SRDP, which is the pathway for actual or potential violations of the physician self-referral law. Upon submission, the obligation to return the disclosed overpayment within 60 days is suspended until a settlement agreement is entered, the provider withdraws, or CMS removes the provider from the protocol.

Notably, being already subject to a government inquiry, including an investigation, audit, or routine oversight activity, does not automatically preclude acceptance of an SRDP disclosure.

Good Faith Investigation of Related Overpayments

Addressed in the following section.

Satisfying the Obligation Through Settlement

A person satisfies the reporting obligations of the regulation by making a disclosure under the OIG SDP or the CMS SRDP that results in a settlement agreement through the process described in the respective protocol. Where that occurs, the disclosure pathway has discharged the reporting requirement rather than merely paused it.

The 180-Day Investigation Window

Alongside the identification change, CMS codified a suspension of the 60-day deadline for up to 180 days while a provider conducts a timely, good faith investigation into whether related overpayments exist arising from the same or similar cause or reason as the initially identified overpayment.

What the Window Is For

It addresses the scope problem. A practice that identifies one improperly billed claim will frequently suspect that the same error affected other claims. Determining how many, across which providers, over what period, is real analytical work. The window exists so that the practice can do that work without the initial identification forcing a premature and incomplete refund.

What It Requires

The investigation must be timely and conducted in good faith. Both words carry weight. A practice that identifies an overpayment and then does nothing for four months before beginning to look has not conducted a timely investigation, and the window is unlikely to protect it.

The related overpayments must arise from the same or similar cause or reason. The window is not a general extension applicable to any overpayment; it is scoped to the propagation of a single identified problem.

Documentation Is the Whole Game

Because the protection depends on the character of the investigation rather than on a filing, the practice’s contemporaneous documentation is what establishes entitlement to it. At minimum, record:

• The date and source of the initial identification, and what specifically was identified
• The date the investigation commenced and who authorized it
• The defined scope of the investigation and the reasoning behind that scope
• The methodology, including how claims were selected and reviewed
• A running record of work performed, with dates
• Findings, quantification, and the date the investigation concluded
• The refund calculation and the date and method of the return

A practice that can produce this file has a coherent account of its conduct. A practice that cannot is reconstructing its own good faith after the fact, which is a materially weaker position.

A Word of Caution

The interaction between the identification standard, the investigation window, and the 60-day deadline is technical and fact-specific. Where the potential exposure is material, the sequencing decisions should be made with qualified legal counsel rather than resolved internally by reference to a general description like this one.

The Six-Year Lookback

Under 42 CFR 401.305(f), an overpayment must be reported and returned if the person identifies it within six years of the date the overpayment was received.

Reading the Provision Correctly

The six years runs from receipt of the overpayment, not from identification. A practice identifying an issue today has an obligation reaching back six years from today for payments received in that window. Payments received more than six years ago fall outside the reporting and return requirement under this rule.

How Six Years Was Arrived At

The proposed rule contemplated a ten-year lookback, corresponding to the outer limit of the False Claims Act statute of limitations. CMS finalized six years in the 2016 rule at 81 FR 7671, a significant narrowing from the proposal.

The Practical Weight of Six Years

Six years of claims is a very large number for most practices. This is why scoping decisions in the investigation phase carry so much financial consequence, and why the same or similar cause language in the investigation window matters. An error correctly scoped to a single provider over eighteen months is a manageable refund. The same error scoped to every provider over six years is a different category of event.

Scoping should be driven by evidence of where the error actually propagated, documented accordingly, and not by either optimism or panic.

A Note on the SRDP

Self-referral overpayments reported to the SRDP were historically subject to a four-year timeframe drawn from the reopening regulations. Disclosures made on or after March 14, 2016 became subject to the six-year lookback under the final overpayment rule.

Reverse False Claims: What Retention Actually Triggers

The regulation states plainly that any overpayment retained after the reporting and return deadline is an obligation for purposes of 31 U.S.C. 3729.

That cross-reference is the entire enforcement mechanism. Under 31 U.S.C. 3729(a)(1)(G), the reverse false claims provision, a party incurs False Claims Act liability if it knowingly conceals, or knowingly and improperly avoids or decreases, an obligation to pay or transmit money to the government. Once the deadline passes with the money still in the practice’s account, the retained overpayment is such an obligation.

What This Means Financially

FCA exposure is not limited to returning the money. It includes treble damages and per-claim civil penalties, which for a practice with a large number of affected claims can dwarf the overpayment itself. It can also carry exclusion exposure and, in appropriate cases, corporate integrity agreement obligations.

The Point Most Practices Miss

The original billing error and the retention are separate acts with separate liability profiles. A coding error made without knowledge of its impropriety may carry no FCA exposure at all, because the FCA requires scienter and an honest mistake does not supply it.

Retention after identification is different. By definition the practice knows. The knowledge element that was absent from the original submission is present in the retention, which is precisely why the government finds these cases attractive: the hard element of proof has been supplied by the provider’s own conduct.

A practice that discovers a billing problem and handles it correctly has a repayment. The same practice sitting on the same finding has an enforcement matter.

The Scope Question: From One Claim to a Pattern

The hardest judgment in this entire area is deciding how far the obligation extends beyond the claim that surfaced it.

Why Scope Cannot Be Avoided

A practice that refunds only the single claim it happened to notice, while possessing information suggesting the same error occurred elsewhere, is exposed. The reckless disregard and deliberate ignorance prongs of the identification standard reach exactly this conduct. Refunding the visible claim and declining to look at the obvious neighbors is close to a textbook illustration of the standard.

A Framework for Scoping

• Characterize the error mechanism. Was it individual and idiosyncratic, or systemic? A single miskeyed entry is unlikely to have propagated. A template that omits a required element, a misconfigured charge rule, or a provider’s consistent documentation habit will have.
• Identify the population at risk. Determine which providers, which codes, which service lines, and which time periods the mechanism could plausibly have affected.
• Test before extrapolating. Review a defensible sample from the at-risk population to determine whether the error actually occurred there, rather than assuming it did or assuming it did not.
• Establish the temporal boundaries. Determine when the mechanism began, which is frequently traceable to a system change, a template revision, a provider start date, or a coding guideline update.
• Document the reasoning. The scope conclusion is a judgment. What protects it is the record of how it was reached.

On Statistical Extrapolation in Self-Disclosure

Where the affected population is too large to review claim by claim, statistical sampling and extrapolation may be used to estimate the refund. This is a legitimate and common approach, and the OIG Self-Disclosure Protocol contemplates it.

It should be done properly. A sampling methodology that is defensible in a self-disclosure requires genuine statistical competence, because the estimate the practice submits will be scrutinized and because an unsound methodology can produce a refund substantially larger than the actual exposure. The same expertise used to challenge a contractor’s extrapolation is used to construct the practice’s own.

The Audit Connection: How Findings Create Obligations Beyond the Sample

This is where the 60-Day Rule intersects with everything else in a practice’s compliance program, and it is routinely missed.

Retrospective Internal Audits

An internal retrospective audit that identifies improperly billed claims has, by design, produced knowledge. That knowledge starts the clock on the audited claims and raises the scope question for the unaudited population sharing the same characteristics.

This is not an argument against retrospective auditing. It is an argument for conducting it deliberately, with a defined response protocol ready, rather than commissioning an audit and then confronting the findings without a plan. Practices that understand this dynamic tend to weight their internal auditing toward prospective, pre-submission review, which prevents errors from becoming overpayments in the first place.

Contractor Audit Findings

When a Medicare contractor reviews thirty claims and denies six, the contractor will recover on those six. The practice then faces a separate question the contractor did not ask: do the same deficiencies exist in the claims that were not reviewed?

The contractor’s recovery does not discharge the practice’s independent obligation with respect to unreviewed claims. A practice that pays the contractor demand and does nothing further, while holding findings that plainly indicate a systemic issue, has an unresolved exposure that is larger than the demand it just satisfied.

Extrapolated Demands

Where a contractor has extrapolated, the projection may already cover the affected population, which changes the analysis. Where the practice successfully challenges the extrapolation and liability collapses to the sample, the underlying findings still exist and the scope question returns. Winning the extrapolation challenge is a favorable outcome that does not by itself resolve the reporting obligation for claims outside the sample.

Failed Educational Interventions

A practice that has been through multiple rounds of a probe-and-educate process without correcting its error rate has an extensively documented record of knowledge. That record is relevant both to the identification standard here and to the scienter analysis under the False Claims Act generally.

Choosing the Return Pathway

Three pathways exist and they are not interchangeable. Selecting the wrong one can forfeit protections or create unnecessary exposure.

Pathway One: Contractor Refund Process

The default. The regulation directs the use of an applicable claims adjustment, credit balance, self-reported refund, or other reporting process established by the Medicare contractor.

• Appropriate when: the overpayment results from ordinary billing or coding error with no underlying legal violation, the scope is defined, and the amount is calculable.
• Advantages: fastest, least costly, no negotiation, no admission beyond the billing correction itself.
• Limitations: does not suspend the 60-day deadline and does not resolve exposure where the overpayment arises from conduct implicating the Anti-Kickback Statute, the Stark Law, or other legal violations.

Pathway Two: OIG Self-Disclosure Protocol

The pathway for potential fraud and abuse violations, including Anti-Kickback Statute conduct and conduct implicating the civil monetary penalties authorities.

• Appropriate when: the overpayment arises from conduct that may violate federal fraud and abuse law rather than from billing error alone.
• Advantages: suspends the 60-day deadline upon OIG acknowledgment, can substantially reduce penalties relative to a government-initiated action, and demonstrates good faith.
• Limitations: involves negotiation, requires a damages calculation the OIG will scrutinize, takes time, and is an affirmative disclosure of potentially culpable conduct.

Pathway Three: CMS Voluntary Self-Referral Disclosure Protocol

The pathway specific to actual or potential violations of the physician self-referral law.

• Appropriate when: the overpayment arises from a financial relationship that does not satisfy a Stark Law exception.
• Advantages: suspends the 60-day obligation upon submission, provides a defined process, and CMS has authority to reduce amounts owed.
• Limitations: Stark-specific, requires detailed legal and financial analysis of the arrangement, and is subject to the six-year lookback for disclosures made on or after March 14, 2016.

The Selection Decision

This decision should be made with counsel. The threshold question is whether the overpayment stems purely from billing or coding error or from conduct with a legal dimension. That characterization drives the pathway, and characterizing a fraud and abuse matter as a simple billing error in order to use the faster route is a serious mistake that forfeits the protections the disclosure protocols provide.

Extended Repayment Schedules

Where the refund amount would create genuine financial hardship, an extended repayment schedule may be available through the Medicare contractor, allowing the obligation to be satisfied in installments.

Program rules address circumstances in which the total amount of outstanding overpayments not covered by an approved repayment schedule reaches a defined proportion of the provider’s Medicare payments for the relevant period, which is one of the triggers relevant to hardship consideration.

Two practical points. First, requesting an extended repayment schedule is a distinct process from reporting and returning the overpayment, and the reporting obligation is not satisfied by the request alone. Second, interest generally accrues on amounts repaid over time, so the schedule addresses liquidity rather than reducing the obligation.

Practices facing a refund large enough to threaten operations should evaluate the repayment schedule option early rather than treating it as a fallback after the deadline has passed.

Building an Internal Identification and Refund Protocol

Given a 60-day clock that starts on knowledge rather than on quantification, the protocol has to exist in advance. The following is a workable structure.

Step 1: Define What Triggers the Protocol

Write down the events that require escalation to the compliance officer. Typical triggers include internal audit findings, external audit findings, payer refund requests, unresolved credit balances above a defined age, employee reports of billing irregularities, denial patterns suggesting systemic error, and coding review findings.

The point of a written trigger list is that it removes discretion at the moment discretion is least reliable.

Step 2: Establish a Single Intake Point

Every trigger routes to one accountable individual, normally the compliance officer, who logs the date received and the source. That log entry is the beginning of the documentation file and frequently becomes the reference point for the entire timeline.

Step 3: Make a Prompt Investigation Decision

Within days, not weeks, determine whether the information warrants investigation. Under the current standard, the question is whether failing to investigate could constitute reckless disregard or deliberate ignorance. Document the determination and its basis either way, including where the decision is that no investigation is warranted.

Step 4: Scope and Commence the Investigation

Define the scope in writing with reasoning, assign responsibility, and begin. Timeliness is a legal element, not merely good practice, and the commencement date should be recorded.

Step 5: Determine Whether Counsel Should Be Involved

Engage counsel where the potential overpayment is material, where the conduct may implicate fraud and abuse law, where a disclosure protocol may be appropriate, or where the scope reaches multiple providers or multiple years.

Step 6: Quantify

Calculate the refund, using statistically sound sampling where claim-by-claim review is impractical. Retain the methodology and the underlying data.

Step 7: Select the Pathway and Execute

Choose among the contractor refund process, the OIG SDP, and the CMS SRDP, execute the return, and retain proof of the submission and the date.

Step 8: Remediate the Cause

Returning the money without fixing the mechanism guarantees recurrence, and recurrence after a documented identification is substantially worse than the original error. Correct the template, the workflow, the system configuration, or the documentation practice, retrain the responsible individuals, and verify the fix by auditing post-remediation claims.

Step 9: Close the File

Assemble the complete record: trigger, decision, scope, methodology, findings, calculation, pathway, submission, and remediation. Retain it for at least six years consistent with the lookback period, and preferably longer.

Common Mistakes

• Operating on the pre-2025 framework. Assuming the clock does not start until the amount is quantified. That linkage was removed effective January 1, 2025.
• Waiting to investigate. Delay is itself the conduct the reckless disregard and deliberate ignorance prongs are designed to capture.
• Refunding only the claim that surfaced. Where information indicates the error propagated, ignoring the related population is exposure rather than restraint.
• Investigating without documenting. The investigation window protects a practice that can demonstrate a timely, good faith investigation. Undocumented diligence is difficult to demonstrate.
• Carrying unresolved credit balances. These are retained federal funds sitting on an aging report, and they are among the easiest exposures to eliminate.
• Treating a fraud and abuse matter as a billing error. Using the contractor refund process for conduct implicating the Anti-Kickback Statute or Stark Law forfeits the disclosure protocols’ protections.
• Assuming a contractor’s recovery resolves everything. Paying an audit demand does not discharge the independent obligation for unreviewed claims sharing the same defect.
• Extrapolating without statistical competence. An unsound methodology in a self-disclosure can produce a refund materially larger than the actual exposure, and it will be scrutinized.
• Applying a de minimis threshold that does not exist. The regulation contains no small-dollar exemption.
• Refunding without remediating. The same error recurring after a documented identification is a materially worse fact pattern than the original.

How DoctorsManagement Supports Overpayment Identification and Response

The 60-Day Rule sits at the intersection of coding, statistics, compliance program design, and legal strategy. DoctorsManagement is a healthcare consulting, accounting, and auditing firm, and we provide the analytical components of that work alongside your legal counsel, who should make the disclosure pathway and characterization decisions.

Our auditors hold both the Certified Professional Coder and Certified Professional Medical Auditor credentials and receive ongoing training through NAMAS, our education division. For matters requiring statistical estimation, our team includes statisticians, economists, and data analysts.

Services relevant to overpayment identification and response include:

• Coding and Documentation Review: Independent determination of whether an overpayment actually exists, which is the threshold question and frequently resolves matters where the initial concern proves unfounded
• Scope Analysis: Characterization of the error mechanism, identification of the population at risk, and defensible sampling to determine actual propagation before a refund is scoped
• Statistical Estimation: Sound sampling methodology and damage calculation where claim-by-claim review is impractical, prepared to withstand scrutiny in a self-disclosure
• Self-Disclosure Support: Damage quantification and supporting analysis for OIG SDP and CMS SRDP submissions, working with your counsel
• Audit Response and Defense: Contractor audit representation, appeal support, and extrapolation challenge, including analysis of what contractor findings imply for unreviewed claims
• Compliance Program Development: Design of the identification, escalation, investigation, and refund protocol, along with the documentation standards that make the investigation window usable
• Remediation and Training: Root cause correction, provider and coder training, and post-remediation verification auditing

What We Do Not Do

We are not a law firm and we do not practice law. We do not determine whether conduct violates the Anti-Kickback Statute or Stark Law, select the disclosure pathway as a legal matter, negotiate settlements, or provide legal advice. Those decisions require an attorney experienced in healthcare fraud and abuse matters, and we work alongside counsel rather than in place of one.

If your practice has identified a potential overpayment, contact DoctorsManagement at www.doctorsmanagement.com/audit-appeal-defense or call (800) 635-4040. The clock runs from identification, which means the analytical work should begin immediately.

Frequently Asked Questions

What is the 60-Day Overpayment Rule?

It requires providers who receive Medicare or Medicaid funds to which they are not entitled to report and return those funds by the later of 60 days after the overpayment is identified or the date any corresponding cost report is due. It originates in Section 6402 of the Affordable Care Act, is codified at 42 U.S.C. 1320a-7k(d), and is implemented at 42 CFR 401.301 through 401.305. Retaining an overpayment past the deadline creates False Claims Act liability.

What changed on January 1, 2025?

Two things. The definition of identified changed from the reasonable diligence standard to the False Claims Act definition of knowingly, meaning actual knowledge, reckless disregard, or deliberate ignorance. And the quantification requirement was removed, so the 60-day clock now starts on identification even if the practice has not calculated the amount. CMS also codified a suspension of up to 180 days for good faith investigation of related overpayments.

When exactly does the clock start?

When the practice has knowledge of the overpayment under the FCA standard. Where the culpable state is deliberate ignorance or reckless disregard rather than actual knowledge, CMS has indicated the period begins on the date the provider acted with that state of mind, not on a later date of acknowledgment. Importantly, a practice that is actively investigating a potential overpayment has not yet knowingly identified one.

Do I have to return the money before I know how much it is?

The clock runs from identification regardless of quantification, and CMS acknowledged that as a practical matter the amount must therefore be calculated within the same 60 days. Where the scope is genuinely complex, the 180-day investigation window for related overpayments and the suspension available through the OIG SDP or CMS SRDP are the mechanisms for obtaining additional time.

How far back do I have to look?

Six years from the date the overpayment was received, under 42 CFR 401.305(f). Note that the period runs from receipt of the payment, not from the date of identification. The proposed rule had contemplated ten years, matching the outer FCA limitations period, before CMS finalized six.

Is there a minimum dollar amount below which the rule does not apply?

No. The regulation contains no de minimis threshold. This is one reason a standing protocol works better than case-by-case judgment, and it is why unresolved credit balances deserve more attention than practices typically give them.

If a Medicare contractor already recovered on audited claims, am I done?

Not necessarily. The contractor’s recovery addresses the claims it reviewed. If the findings indicate the same defect exists in claims the contractor did not review, the practice has an independent obligation with respect to those claims. Paying the demand and taking no further action while holding findings that plainly suggest a systemic issue leaves exposure unresolved.

Which disclosure pathway should I use?

It depends on the nature of the conduct, and the decision should be made with counsel. Ordinary billing and coding errors generally go through the Medicare contractor’s refund process. Conduct potentially violating fraud and abuse law goes to the OIG Self-Disclosure Protocol. Conduct implicating the physician self-referral law goes to the CMS Voluntary Self-Referral Disclosure Protocol. Both disclosure protocols suspend the 60-day deadline; the contractor refund process does not.

Can I use statistical sampling to calculate the refund?

Yes, and it is common where the affected population is too large for claim-by-claim review. The methodology must be statistically sound, because the estimate will be scrutinized and because an unsound approach can produce a refund materially larger than the actual exposure. This requires genuine statistical competence rather than a spreadsheet estimate.

What if returning the overpayment would put the practice in financial distress?

An extended repayment schedule may be available through the Medicare contractor, allowing payment in installments. Requesting one is a separate process from reporting and returning, and interest generally accrues, so it addresses liquidity rather than reducing the obligation. Evaluate it early rather than after the deadline has passed.

How can DoctorsManagement help?

We provide independent coding review to determine whether an overpayment exists, scope analysis and defensible sampling, statistical damage estimation for self-disclosures, audit response and extrapolation challenge, compliance protocol design, and root cause remediation. We are not a law firm and work alongside your counsel, who should make the pathway and legal characterization decisions. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• 42 CFR 401.305: Requirements for Reporting and Returning of Overpayments
• CMS Medicare Overpayments Fact Sheet (MLN006379)
• CMS Medicare Financial Management Manual, Chapter 4: Debt Collection
• OIG Self-Disclosure Information
• CMS Voluntary Self-Referral Disclosure Protocol
• CMS Physician Self-Referral Overview
• Department of Justice: The False Claims Act
• OIG Fraud and Abuse Laws for Physicians
• OIG Work Plan
• CMS Regulations and Guidance
• DoctorsManagement Audit Appeal and Defense
• DoctorsManagement Coding and Documentation Review
• DoctorsManagement Healthcare Compliance Audit
• DoctorsManagement Total Compliance Solution

The overpayment regulations were substantially amended effective January 1, 2025 and remain subject to further revision and to evolving judicial interpretation. The application of the identification standard, the investigation suspension, and the lookback period is fact-specific. Practices that identify a potential overpayment should promptly consult qualified healthcare counsel. DoctorsManagement is available to provide the coding, auditing, statistical, and compliance program components of the response.

Contact Us

This article is provided for informational and educational purposes only and does not constitute legal advice. DoctorsManagement is a healthcare consulting, accounting, and auditing firm. It is not a law firm and does not practice law, determine whether conduct violates federal fraud and abuse law, select disclosure pathways as a legal matter, or negotiate settlements.

The post The 60-Day Overpayment Rule: What Changed in 2025 and Why Finding an Error Starts a Clock appeared first on DoctorsManagement.

The COVID-19 pandemic, misinformation, and shifting guidance have led to a significant erosion of trust in health care institutions, making it challenging for physicians to effectively communicate evidence-based information to patients. Physicians still maintain a high degree of trust with their individual patients, and have an opportunity to serve as ambassadors for science and evidence-based medicine in their communities.

Hosted by Stephen Parodi, MD, executive vice president at The Permanente Federation and The Permanente Medical Group, this Permanente Live webinar explored insights from national leaders in health care:

• Jason M. Goldman, MD, MACP, immediate past president, American College of Physicians; internal medicine physician
• Letitia Bridges, MD, MBA, executive vice president and chief quality officer, The Permanente Federation

The conversation covered timely topics like:

• The challenge for physicians and patients that the environment of medical misinformation and mistrust in public institutions poses.
• The importance of physicians and health care organizations developing their own evidence-based guidelines and resources and engaging with the public beyond just the clinical setting, to help rebuild trust in expertise and evidence-based medicine.
• The need for physicians and health care leaders to prioritize safety and accuracy when evaluating AI and other new technologies.
• The value of strategies like open communication, acknowledging uncertainty, and actively listening to patients.

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Stephen Parodi, MD: Hello everyone and welcome to our Permanente Live webinar, Evidence Under Pressure: Medical Excellence in An Era of Misinformation. I’m Dr. Steve Parodi, executive vice president of the Permanente Federation and The Permanente Medical Group. And thank you for joining us today. I encourage you to amplify the conversation on social media using the hashtag #PermLiveLeadership. And as you listen to our discussion, please submit any questions using the Q&A function in this Zoom meeting. We’ll ask our guests your questions a little later. Accessibility and the nature of medical misinformation has been transforming over the last several decades. Information technology, social media, and artificial intelligence are all defining how an individual seeks answers to their medical questions. Professionals, patients, and policymakers are questioning the reliability and impartiality of sources they’ve long trusted. Replacing trust are the unwelcome elements of apprehension and suspicion between clinicians, patients, and families. Democratization of information on the other hand can level the playing field and lead to a more substantive conversation about clinical care and heightened ownership of a patient in their own health outcomes and health overall.

Beyond the day-to-day realities of our exam rooms and hospitals, changes to federal agencies have led to some to question the scientific guidance issued from these time-honored institutions. The restructuring or wholesale dismissal of national expert-led committes and subsequent changes to policies pertinent to vaccines, preventive services, women’s health, and host of other topics have had far reaching real-world consequences. Increases in contagious diseases and maternal mortality are just some of the consequences we are wrestling with as a country. The impetus to respond has led to the rise of alternatives where our organizations are banding together to produce evidence-based guidelines due to what appears to be an existential threat to public health. And despite all of this upheaval, trust between doctors, nurses, and their patients remains high. People still actually value that deeply personal relationship. So thank you all for joining us because what’s a busy practicing physician supposed to do in this new world?

And to make sense of all of this, we are joined by two national experts. Dr. Jason Goldman is the immediate past president of the American College of Physicians and Dr. Tish Bridges is the chief quality officer at the Permanente Federation and co-chair of the Kaiser Permanente National Quality Committee. What does it mean to deliver high quality care while maintaining trust and credibility in a highly partisan environment? How can public institutions still support the dissemination of evidence-based medicine and information? What needs to look different? Jason and Tish, thank you for joining us today. Jason, I’m going to turn to you first and maybe help level set this whole conversation. So federal guidelines have shifted and many physicians seem to be more concerned about the decisions that are being made right now and the evidence that they’re based on. So what’s different about this environment and are these concerns valid?

Jason Goldman, MD, MACP: That’s an excellent question. First, thank you for having me. This is an absolute pleasure to participate in this forum. It is very concerning what has happened to our entire public health infrastructure and the policies and the stance that has been created and how things are changing. We used to look at our institutions. We used to look at policy committees, public health committees as sacrosanct and they gave the information these were our guidelines. We could trust them. We had the evidence and that would shape how we as physicians are able to take care of our patients, what we can fall back on, how we can look at that information, make the best possible recommendations. We’ve entered this era where there’s so much mistrust, misinformation and challenge to the very fundamentals and foundation of our public health infrastructure that it’s very difficult to know what guidance we can rely on, where can we turn to and how we can best take care of our patients.

And it affects not just us as physicians and having those guidance, but also our patients because they’re getting mixed messages. And when they come into the exam room and they ask us for our opinion, they’ll turn around and say, “Well, we have other opinions from other doctors who are saying the exact opposite.” So it makes it very challenging for who the patients can trust. You are right, there is that initial [edit] or that still the foundation that the patients want to trust their personal physician, but they’re being inundated by so many different sources from so many other sides making it very challenging in this environment to get the information out there to the patients where it needs to be and for them to have a trusted voice.

SP: Thank you, Jason. Tish, what are you hearing directly from practicing physicians? How are these changes actually affecting them, to Jason’s point? The inundation of all the information coming in, whether it’s on social media, whether it’s your own patients, whether it’s Dr. Google, and it’s no longer Dr. Google, it’s Dr. AI. So what do you think about all of that?

Letitia Bridges, MD, MBA: Great question. And again, thank you for facilitating this conversation. It is a vital one I think for all practicing physicians. What physicians are feeling now is frustration with not conversations that are new that really reveal a lot of the challenges that they’re experiencing in the external marketplace, but they’re really feeling this uncertainty themselves around what is the evidence, how is it accurate, how is it evolving, and how do I bring that into my practice from one day into the next? And so as I’m traveling the KP enterprise and talking to various physicians, there are deep concerns about sources that they’ve always trusted. And I think Dr. Goldman hit on this beautifully. We have come to learn that the USPSTF is a source of guidance for us. We’ve come to rely on what comes out of the FDA and there was a natural trust there that information coming out of these alphabet soup agencies were really that it was reliable.

And I think the unsettling feeling here is just the uncertainty as we step into the clinical practice arena. I’ll share a really interesting story from one physician who is racing to care for patients, but is also really attempting to be very diligent in keeping up with his ongoing education. And he asked me a couple of weeks ago, “Well, can I still trust this source?” And I said, “Well, yes, that’s still a trusted source.” And he said, “Well, how do I know? I mean, I can’t trust anything anymore. The ground is constantly shifting beneath me.” And what we talked about was really this opportunity as physicians to continue to step into this space to really deeply understand what we’re managing towards and at least within Kaiser Permanente to lean upon the systems that we’ve already launched. We spend a little bit of time talking also through how we evaluate evidence within our own enterprise and how that shows up in our clinical practice.

And so really at this time, I think the opportunity for us is to not only to continue our national advocacy, we need to really be involved in these spaces, but we also should be thinking heavily about how we get involved with evidence synthesis conversations within our own specialties, how much attention we’re paying to our own medical societies and understanding and living the standards, but then also the clinical practice guidelines that we are developing together, we all need to have the opportunity to be into those conversations and to build them into the EMR, to build it into the conversations and to use that clinical knowledge that we have internally vetted to really drive the care that we deliver.

SP: Tish, I really appreciate what you just said. And as I think about this, Jason, Kaiser Permanente, we actually have a clinical library, it actually is maintained by physicians, physician leaders, experts, researchers, and we modify it and update it. And of course it’s directed towards our clinical practice and value-based care. We’ve had to modify it recently. So a lot of the evidence to Dr. Bridges’ point here in terms of the physicians are saying, “Well, wait a second, can I trust X, Y, or Z federal agency?” And you referenced it in your clinical library. In fact, we’ve modified it and I’ll cite ACP is sometimes now being substituted for some of these other named agencies What’s happening nationwide? Is that just a phenomenon within Kaiser Permanente or is it broader?

JG: It definitely is a much broader conversation and it comes down to who can you trust? In the past, you trusted your physician, you understood they went to medical school, they got their degree and the weight of those letters, MD, DO, behind your name, came with that certain trust factor and acceptance that we all agreed these were experts, these were well-trained professionals. What we have lost is the acceptance of expertise. There’s a book written a while ago, The Death of Expertise. And the sad part is whether it’s the democratization of information or the internet or everyone can just find whatever they want and may or may not know how to interpret it, we no longer accept, [edit] or many people just no longer accept expertise for what it is and they question everything. So on one hand, we have lost that basic trust in just the simple conventions of who we can trust.

And that’s a shame because we no longer have that level playing field. So we then have to ask, “Well, who can you trust?” As you said, we look at the ACP. We’re one of the only, if not the only medical organization that is a GRADE and AGREE center, which means we have the highest level of standard for evidence review when we make our clinical guidelines. I think part of the problem when we look at our patients, when we communicate to the media, to the press and to the public at large is people don’t necessarily appreciate what that means and how we come up with our guidance. With that strict requirement for GRADE and AGREE, we have to have good foundational evidence in order to put out a policy paper. And if we don’t have evidence, then we may not be able to comment upon it because we can’t substantiate it, but absence of evidence does not mean evidence of absence.

We just may not be able to rely on a study that we have, but that doesn’t mean we aren’t trusted information and that has been lost to the public. In one of my other roles, I’m the ACP’s liaison to the Advisory Committee of Immunization Practices, which we all know has come under fire in the past year with vaccine recommendations, which caused ACP and several other organizations to step in and fill that gap by publishing our own vaccine guidelines. But one of the points I wanted to bring up is that many people don’t see, to use the vernacular, how the sausage is made. They don’t see the work that goes into the committees that we serve on to be able to come up with these guidelines and just how robust and in depth that evidence review is before its final presentation before the committee before a vote.

And in that absence of knowledge or people refusing to see how it’s done, they claim there’s no transparency and in the shadows or the gray area they say, “Well, you can’t trust them.” But if they actually looked and actually went in depth and saw the transparent processes that ACIP, ACP and other organizations use, they would say, “Oh, we can trust them because there is actually a standard transparent evidentiary process in how they came up with those conclusions.” And sadly, I think that is what is missing and what is being capitalized on is the innuendo and the gray areas that people are using to claim you can’t trust various agencies when in fact you can.

SP: So just a quick reminder to everybody, if you have questions, please submit them using the Q&A feature. And again, we’re going to try to get to all or as many of your questions as we possibly can. Tish, I was just listening to Jason here and I know a lot of the focus of misinformation has been related to patients and patient consumption, but it’s not restricted to just patients. It’s clinicians. And by the way, there’s a spectrum there. And so I’m interested, you represent an organization that has 25,000 physicians and there is a vast diversity amongst that population in terms of the consumption of this information, the interpretation and then actually application of it. What do we do and how are you tackling it as the chief quality leader within a big organization?

LB: So thank you for the question. And it does very much link with the conversation that Dr. Goldman was just taking us through and I will answer the question in two ways. The first is our 25,000 physicians need to know how much our own research contributes to the evidence that sits out in the general public. I love to communicate with our physicians around our vaccine safety data link, for example. We actually produce the data that has been used by ACIP in order to determine the guidelines that we followed. And so within Kaiser Permanente, we have this incredible history of being active participants in the research that we need to deliver on our promise of public health. And so we start with that communication, but what’s really important is that as a physician, you will hear me loudly and often communicate two things. The first is policy has no role in the exam room.

In the exam room, it is “What is the evidence” and keeping us focused on what we are here to do, which is high-quality care that is accessible for all, that’s really the focus. And the way that we get to that value-based care is by delivering on the evidence. And our clinicians are excited about many new tools, the open evidence, the ChatGPT. I mean, there’s so many different frameworks that folks are using to find the evidence, but reminding them that we are diligent about building the tools into their clinical practice, bringing these tools through our CME infrastructure, also incredibly important lunchtime meetings, really pushing in on that education as a follow-on to the understanding of where the data comes from and how we participate in that. I think the combination of those two incredibly powerful. As we think about the physician group writ large, we do have the opportunity to continue these conversations.

And one of the valuable frameworks that you’re bringing actually is to just open up the dialogue between us and all facets of the government. I think the amount of engagement with government relations also powers a lot of the understanding so that folks can really start to understand what’s happening in the external environment. And in many ways it helps them to make sense of what they’re reading and what they’re seeing because our physicians really need to translate this for our patients and that translation really requires foundational knowledge. And so I would say those three pillars are really the core aspects of the approach to help our physicians navigate what has become a very difficult environment.

SP: Jason, thank you, Tish. I want to pull on a thread here and I’m going to reflect, maybe this is recent conversations that are guiding me here. So I was literally talking to our information technology leader yesterday about AI and the use of it within our clinical practices. And really the question was, “what kind of training do we need to be providing?” And there’s the spectrum of clinicians who hopefully they’re going to practice for 30 years. I think I’m looking at the two of you. I don’t think any of us had AI in our world when we were training and yet it is part and parcel to our practices now. And on top of that, you’ve got people coming up who that’s the world they’ve lived in. They trained in college and or med school and it’s natural to them. What do we need to be thinking about from a medical education perspective, whether that’s undergraduate, graduate and/or continuing medical education? How does ACP think about it? How should other specialty societies be thinking about it?

JG: I think about that a lot because it’s been an explosion overnight with AI just integrating into every aspect of our lives from medicine, the exam room to how we function on a day-to-day basis, how we communicate, whether we think it’s good, bad, or indifferent, it’s here and we need to face it. One of the things as physicians, we’ve all been taught to be critical thinkers. We have been trained to review studies, to look at data and evidence to question, to come up with our own conclusions, we need to apply that same critical thinking to everything we do, but we also have to balance that with implicit bias, which we all have and recognize what we’re leaning towards and how we’re filtering that data. When we look at artificial intelligence, for many people, physicians included, the natural reaction is you read it, it must be true, it cultivated sources, it’s saying that it has evidence so we just accept it at face value, but that’s where we have to be very careful.

And ACP is looking into policies on AI and how we best approach it and how we use it in practice. One of the things at least that the American College of Physicians has done is partnered with DynamedX, which does have AI, but it’s within a walled garden. So all of the data that it’s using is vetted and cultivated from ACP guidelines and policies and sources that are trusted. So it’s not going to hallucinate and pull out information from other places. So you have to know where you’re getting that AI information from, how does it filter the information and what is it using to be able to come up with its conclusions. Otherwise, you may run down a rabbit hole of wrong information and poor patient care. So it really comes down to applying the same critical thinking and standards that we do for everything in medicine from reviewing studies to differential diagnosis, to analyzing patients, to whatever our own Google or other research or DynaMedex or UpToDate or OpenAI or whatever is used and really apply that same critical thinking and skeptical lens to be able to make sure the information can be trusted.

LB: This is a fantastic topic. As we think about AI, the promise is certainly there and I agree it’s here. We’re actively using it and we really want to think about this through the lens of safety. We want this to be a tool that accelerates us. And as we all know, acceleration can be both positive and negative. And as we’re considering what we bring in, we need to understand how these tools are created, what data it’s trained on, and to your original question, how the physicians are prepared to evaluate the use of these tools. We talk a lot about keeping a human in the loop as it relates to this, particularly in care delivery decision-making, but there’s a few steps before that. And one of the big initiatives that we’ll be rolling out over the next several months here is that we will have active CME education for all of our physicians to help them both recognize the tools and to help our physicians understand what the tools are and what the risks will be in using those tools.

And so this is a critical area for us. And I would also say that our physician leaders that are operating in this space, they’re really learning and evolving and training differently, understanding how to read a data use agreement. That is not anything that any of us learned in medical school and yet it’s critically important for physicians to really feel comfortable at this intersection between clinical care and technology. And so for those of you on the call that are already in this space, I want to first of all applaud you, but I also want to challenge you to remain engaged and to bring everyone along. I think this is that next evolution that we probably haven’t had since we launched our EMR and our ability to integrate and to use this tool, to use this tool to design our systems to make it more efficient and effective for us, tremendous opportunity here and just very excited about what the future will bring as it relates to AI, as long as we’re thoughtful about the safety constructs and the governance that we put around it.

SP: All right, got some questions rolling in. I think you’ve generated some interest. All right, let me ask you the first question that I think is a little provocative. All right, the United States has often been a trusted source of information when it comes to medical information and leadership. Given what’s going on right now, what other sources should we be thinking about as physicians? Do we need to be looking at international sources, other places to get that information, or do we actually still have it in the US? We just need to look in different places.

JG: I’ll try and be parsimonious with my comments. This is an overused word, but these are unprecedented times. The fact that we see an active attack on science, on expertise, on our very evidence and reality in some cases is challenging. Yes, we do need to always be open-minded, look at other sources. When you look at European guidelines, when you look at the WHO, when you look at Canada, for example, and their guidance on different treatments, we need to have the same critical evidence review. We have to look at our medical organizations, the American College of Physicians and others, and use those as credible sources. It’s unfortunate that as I circling back to what I opened with, we can’t necessarily still trust what was sacrosanct because those institutions for political reasons have been compromised and it’s going to take generations, I fear, to get back to a place where we can have that trust again, but we really do need to rebuild that foundation.

And no matter what policy administration is in place, we need to have a consistent, transparent, evidence-based process that can always be turned to regardless of the political forces that are affecting them because you’re always entitled to your own opinion, but not your own facts. The facts don’t change, the evidence doesn’t change, and the process needs to be in place no matter what. So yes, we can and do need to look at other sources of information, but we also need to make sure we see the transparent evidence-based process in how those guidelines and policies and recommendations came to be.

LB: My perspective is that the federal government has rewritten how we should be thinking about our standards. It’s just that simple. They’ve pulled themselves out of the scientific conversation pushed into a policy space that does not serve the clinical practice needs for physicians in this country. And so the challenge and the opportunity is in this new world order, what should we build that actually gives us the evidence that we need? We’ve always been fantastic with scanning evidence sources both national and international. We have been fortunate for the last 60 years that we’ve had an infrastructure that we could trust, but before that, remember we did not. And so in many ways we have to go back to practices that we’ve had in the past, which is coalitions, which looking at international data, thinking about what it is that we need. And then as physicians, as a community of researchers, as a community of health systems, insurance companies, everyone that has a vested interest, we need to figure out what these new coalitions will look like moving forward and form our new infrastructure.

And I think this is exactly what Dr. Goldman was calling out. And so I would really beseech us to quite frankly accept that the government has stepped out of the trusted role that they have offered in the past and for us to spend much more time building what comes next that will be both resilient against any future policy infrastructure, but also facing the patients in a way that is deeply meaningful to the ethical practice of medicine.

SP: Tish, this next question actually pulls on a thread that Dr. Goldman had brought up earlier, which was in some ways he was raising the idea that actually the public policymaking amongst physicians is actually a time-honored tradition. It’s actually be good to be transparent about it. On the other hand, some of that transparency during the COVID era was not embraced. In fact, it was seen as uncertainty or confusion. And so I guess the question I’ve got here which relates to this is, are there lessons learned from the earthquake that we just went through for the last four and a half, five years when it came to COVID where there can be logical and reasonable evidence-based disagreements? And what should we doing as physicians to embrace that, amplify that, and also explain that in a way that is understandable to the general public? Is there anything that we’ve learned from our experience last five years?

JG: I co-authored an op-ed actually that was published in Annals basically saying lesons learned from COVID, flying the plane while building it. And one of the biggest issues is communication and explaining to the public and even to our own physicians, embracing the uncertainty. Science is an iterative process. We constantly are learning. We come up with a theory. We try to prove that theory, and if it proves not to be true, we move on to prove something else. We don’t try to keep re-litigating just because we want to believe something. We have to accept the evidence and also explain what we don’t know. And that is scary for many people to admit, I don’t know something, or we don’t have the evidence. And that was attempted to be done during the COVID pandemic, but it was such a chaotic time some of that messaging was lost.

So one of the biggest lessons is explaining to people what we know, what we don’t know, where we have gaps in evidence, where we need to learn more, and to say, “We’re unsure about this. We don’t have the answer. This is what we’re trying to find out. ” But that is applicable not only to the public, but also to our individual patients when we’re in the exam room. Say, “I don’t know what you have, but we’re going to try and figure it out, but we may not be able to, but this is what we’re going to do to try and get you better.” So it’s about clear, honest, open communication and admitting when you don’t know something.

LB: I love that response. And as we think about navigating the last five years, we’ve learned many things, but one of them is really just the deep discomfort in this country, quite frankly, with uncertainty and the need to create a polarized yes or no, black or white. And that’s not really the point and purpose of science. When we think about the scientific method, it really is about there’s a question we’re going to try to answer it. There’s this inquiry that’s built into it and there’s this willingness to evolve and to pivot and to move. And I think that as I think about lessons learned, it is comfort in moving in uncertainty and it is also a shared vision and purpose. What I loved about COVID was that we came together in ways that I had never seen before. We came together across hospital systems, across payer groups, across entities, kind of writ large.

We had a shared purpose and we were constantly and aggressively working towards that. And this latest crisis, I call it the crisis for lawyers because my perspective that it’s mostly the lawyers out there generating all of this. And we need to figure out how we can come together in order to resolve the policy crisis that I think we’re facing. And so when we think about COVID, science did save us. I don’t think that we say that out loud, but it is definitely true that the scientific process ultimately saved us from that latest crisis. And the same is also true of today, valuing the science, understanding and using the scientific process and convening together with a shared purpose. That’s the way out of this, quite frankly, and every other crisis that will come our way.

SP: So Tish, to follow up on that, because we’re talking to individual practicing clinicians here, what does someone need to do in the exam room in this new environment? I mean, there are just some cold, hard realities. I mean, I still treat infectious diseases. They still exist. Heat-related injury issues, climate-related issues are realities in our exam rooms, yet these have been politicized and/or subject to partisan discussion. And we all come with our various backgrounds by the way, whether it’s on the clinician side or patient side. So in that environment, what is the optimal aproach for a physician in this day and age when they’re having those conversations in the exam rooms? What’s Kaiser Permanente doing? Are we training people to talk about these conversations?

LB: Yeah, that’s a great conversation. At the end of the day, the patient-physician relationship is about trust. And in those exam rooms, as busy as we are, we have to sit with the discomfort of some of these really challenging conversations that we need to have. Patients are certainly coming in with deeply held beliefs that may or may not be rooted in science, that may or may not be rooted in common sense. And I think after the 15th conversation of the day, it is tempting to just throw your hands up and say whatever. I think this is the opportunity for us to really demonstrate who we are. And as a profession, we are people that deeply care about people, about our communities, about our country. And that has to be reflected in the conversations that we’re holding one-on-one and the willingness to share both sides of the conversation to hear what the patients are solving for.

I take particular interest in learning where they’ve received their information because the sources sometimes are quite amusing. But really this is about our ability to have those crucial conversations with patients and to have the resilience to do that on repeat mode. I will say that as an organization, we’re thinking through a couple of things. The first is really the use of motivational interviewing. It is incredibly empowering for physicians to sit with patients and to deeply understand what the patients are solving for. And I think that conversation takes us away from some of these dichotomous beliefs around clinical practice standards and really puts us back into the realm of how are we solving through your medical challenges together? What matters to you? How can I support you on that journey? And removing some of the friction from the communication that comes I think is a large part of the training that we’re taking on.

We also know that there’s an explosion of cognitive behavioral science that’s really helping us to learn to navigate some of these conversations differently. And I think we also need to take advantage of the longitudinal care that we have. Not all challenges can be solved within one visit. And how are the non-physicians really supporting these conversations? What does it look like at scale for the team to really support us as we’re moving forward in a very difficult space? Because this misinformation is not going away. I mean, it is deeply rooted and I love what Dr. Goldman said earlier. I do have the perspective that the environment that we’ve lived in in the last two years will be unsettling for us for decades to come. This is not about a four-year term. We have an entire system that needs to be rebuilt and we have to yet again in crisis lean on our physicians and really inspire them to continue the difficult conversations that exist out there.

And what I will say to wrap this little question is that I always remember sitting in that exam room that I’m not just talking to that patient. I’m talking to that patient who will interface with their husband, with their children, with their grandparents, with their best friends, with the people that they work with. And as physicians, we’re a little bit of a star. I mean, we have this energy that can radiate out across our patients into their environment and we can start to change the narrative one patient at a time even when we’re frontline physicians in the exam rooms.

SP: What an amazing comment to say that we are stars in our exam rooms. Thank you, Tish. So on that sort of note, Jason, I’m going to ask you both the same question here. What’s a concrete example that you’ve seen or heard from a physician leader that has successfully strengthened trust in their patients or their communities? So go broader than just the exam room itself that’s led to either greater belief in evidence-based care or an amplification of that. So Jason, I’m going to give you the first crack at that one.

JG: So I was thinking a lot about what Tish was saying and there’s definitely the movable middle that we talk to. There’s some on both sides of the spectrum which you will never reach. There are those who agree and then those who disagree, they’re each in their echo chamber. No matter how many conversations you have, no matter what approach you have, no matter what you do, they’re entrenched, they have their belief system, you’ll never break through. It’s really that movable middle who’s unsure, who wants more information, who is able to accept and receive new evidence that you can work with. I remember having a conversation with Dr. Ashish Jha and he gave an example where he had a patient discharging from the hospital and they had a great visit, took care of him. He had a heart problem, got him better. And upon discharge they were joking, laughing, great interactions.

And then, “Oh, by the way, have you gotten your flu shot?” And the conversation dramatically changed, the demeanor changed, and it became the, “Well, how much are you getting paid to give me that flu shot? What’s the bribery that you’re getting?” He’s like, “Really? Tell me more.” And so it’s that simple phrase, “Tell me more.” Because you’re engaging the patient, you want them to talk, you’re not berating them, you’re not saying, “Well, that’s ridiculous.” You’re not challenging them. And as the story went on, the patient’s like, “Well, the pharmaceutical industry’s paying you. ” Okay, how? Walk me through that process. How do you think that occurs? And when you start delving into it and the patient, you let them talk in the narrative, it’s like, okay, well, I kind of see you’re right. Maybe there’s no actual way to pay you and I’m not really sure how it happens, but that’s what I’ve heard, yet it kind of doesn’t make sense.

He still didn’t get his flu shot, but there was narrative, there was dialogue. So both on an individual as well as a global, it’s about active listening. It’s about the narrative. It’s about letting the patient or the individual or the public at large have that expression as long as they’re willing to listen in return. And that’s why it’s communication and it’s a give and take because the hammering, the beating down, the “you are wrong, you need to do this” it falls on deaf ears. And there’s some people, no matter what we do who will never listen, but for those who are willing and you engage with, okay, well, I’m trying to help you. Explain to me more so that I can help you better. And that really, for me, is a approach we can use in many aspects of our lives, not just the exam room, when engaging with someone who is not sure of how they can trust you, getting them to engage with you and being willing to listen to them.

SP: Thank you, Jason. And Tish, I’m going to probe you on top of this. So that question to you, but also is there a role for the physicians outside the exam room? Should we be doing podcasts like this? Should we be on social media? What else should we be doing? Or do we stay in our lane? And what is our lane?

LB: Well, I deeply believe that as a physician, we have both a role and responsibility outside of the clinical practice. And Dr. Goldman here leading the ACP, I mean, that is just an incredible example of how the shared vision that we have can actually be propagated across the country and even internationally. And so I would say a couple of things. The first is I love this idea of the movable middle. We’re always talking about do the work that can be done and be persistent with that and finding your shared purpose with the patient and really taking the time to explain it. I mean, that’s really valuable. I don’t know about you guys, but I’d love to know how the pharmaceutical companies are paying me. I’m missing those checks. But if that’s a narrative out there, we need to have the opportunity to speak to it. And yes, more presence on social media.

But even beyond that, because some of us are not natural hams, some of us have never posted on any platform. Okay, that’s me. But as we move forward, we have our churches, we have the schools that our children attend. We have random conversations in the airport. We need to be ambassadors of not only science, but actually wellbeing and health and togetherness because these concepts, that gets to the core of medicine. And my personal perspective is that we’re all super busy in our clinical lives. And now is the time for us to not only maintain those clinical practices, but really to lead the dialogue in a different way. The only reason I think that the dialogue is where it is, is that we have this polarizing conversation that’s happening on one side and we really need to bring that dialogue back to the middle as Dr. Goldman said, but with all of those people that are already on board, I think we have the silent majority that needs to actually unmute.

SP: I love that, Tish. I think what both of you are characterizing here is that actually we never take the white coat off regardless of where we are, whether it’s in the real world with many of the examples you gave, Tish, or it’s in the virtual world that Jason, we were talking about, or whether it’s even the AI world, people embrace physicians as leaders and they still respect us. And what you’ve outlined for us today is how that’s evolved and how it will continue to evolve. And that’s really what we do as doctors anyway. We evolve with situations, whether it’s the actual patient situation and now it’s actually the larger societal evolution. I really want to thank both of you for joining us today. I want to thank everyone else, our audience for joining. And I’ll just sort of close with a couple of comments here that as physicians, we really have a responsibility to ensure our patients get the best care possible and serving as partners in their decision-making for their own health.

And we know that uncertainty and misinformation may continue to grow. In fact, it may just be our new reality, but a strong, trusting physician, clinician and patient relationship is really ultimately the best defense. And health system leaders, specialty societies, associations, and other professional groups can and must continue to support medical practices and our practical resources as we navigate healthcare’s most pressing challenges. Look for a link to the webinar recording in your email and don’t forget to share it with your network. And also be sure to follow Permanente Medicine on social media to learn about the future programs that we’re going to have and check out permanente.org for our library of past videos and podcasts. Thank you all for joining us today.

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In this episode of the Permanente Medicine Podcast, host Chris Grant sits down with John Yang, MD, president and medical director of the Hawaii Permanente Medical Group (HPMG), to explore the unique culture and community-oriented approach to health care delivery in Hawaii.

As the leader of the state’s largest physician-led multi-specialty practice, Dr. Yang explores the geographic, demographic, and public health challenges of delivering care across the Hawaiian islands. The conversation digs into how HPMG has leveraged health care innovations to overcome access barriers across the islands.

Listeners will learn how deep community ties help build the trust needed to effectively support communities during natural disasters, like the devastating Lahaina wildfires. The episode highlights how cultivating deep community relationships and cultural understanding drives better patient outcomes both in the exam room and beyond.

Dr. Yang also discusses HPMG’s proactive efforts to build a sustainable physician workforce, including growing their own talent through local training programs and providing robust support for clinician wellbeing.

Watch the full episode on YouTube:



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Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

John Yang, MD: The culture here is very much relationships. It’s about getting together. It’s important to invest in these relationships before problems arise. I think as we try to get groups together when there’s a crisis, if we don’t have that foundational relationship, then the trust is not there and we’re not able to work through things as effectively.

Chris Grant: Welcome to the Permanente Medicine Podcast. I’m your host, Chris Grant, the chief operating officer of The Permanente Federation at Kaiser Permanente. Today, I’m joined by a dear friend, Dr. John Yang, president and medical director of the Hawaii Permanente Medical Group. He leads the state’s largest physician-led multi-specialty practice with more than 700 physicians and clinicians providing care for 270,000 members across the state. From its geography and landscape, diverse population, and health needs, Hawaii is a unique health care environment. Today, we’re excited to explore the challenges and opportunities of practicing medicine in Hawaii at the community level and across the state. I’m really excited about this conversation because when we were together recently in Washington, D.C., meeting with congressional leaders to talk about Permanente Medicine and value-based care, I was so impressed with how you, Dr. Yang, shared our Hawaii story. And I know the policymakers were too. So now it’s time to turn to our audience and help them learn about your amazing work. Welcome and mahalo.

JY: Thank you. Thanks for having me. Excited to be here today.

CG: All right, let’s dive in. Before we get too deep into the conversation, John, tell us a bit about your journey into medicine and what ultimately drew you into medical leadership.

JY: So I was born and raised in Southern California, left California for about 8 years for medical school, for my family medicine training. Did a one-year fellowship in faculty development and medical informatics, and then ultimately returned to Southern California. I joined SCPMG in Orange County in 2001. I also always had an interest in technology from building my own computers to doing that medical informatics fellowship. And around this time, there was lots of discussion around the promise and the future of electronic health records. I feel like in some ways I got into leadership by accident. I always had a desire to make things better, improve processes, workflows. I would tend to ask a lot of questions and really be willing to try new things. And as I look back now, and I think a couple of experiences really helped shape the foundation of my leadership journey in addition to the many mentors that we all have that shape us personally.

Taking on a role as the physician-in-charge in a large multi-specialty clinic in Orange County, that was the foundation of helping me understand clinical operations, and it was also the foundation of the value and importance of a physician-led medical group. I was leading primary care in Orange County, but had this unique opportunity to come to Hawaii in 2020 in the midst of COVID. Very challenging time, lots of unknowns. But as I reflect back, super proud of our being a part of the state of Hawaii’s outstanding COVID response. Hawaii managed that pandemic highly effectively. We had some really unique things that we’re super proud of. We achieved the lowest age-adjusted COVID-19 death rate in the US, the lowest rate of excess mortality, all in the middle of the ocean in a place that didn’t always have all of the resources that other places have. Thinking back on why the state was so successful, I think a lot of combination of things, but things that mattered, rapid geographic containment, swift policy interventions, high vaccine compliance, and something that we didn’t see everywhere else was a deep community cooperation.

I’ll leave you with one fact that I think is pretty impressive that KP Hawaii delivered over a million doses of COVID vaccine. I’m pretty remarkable when you consider the population of Hawaii is about 1.4 million.

The importance of trust and cultural understanding in practicing medicine

CG: That is amazing. It’s delivering vaccines to 70, 80% of the entire state. It all makes sense to me of why you’re so successful in Hawaii because Hawaii is so relationally oriented and understanding people and building trust is really what it’s all about. What a heroic situation to dive into, to relocate to Hawaii, to one of the most isolated places of geographic concentration on the globe, and to be very responsible for the COVID response, not just to the Kaiser Permanente members and patients, but to the entire population. Speaking of culture and diversity, Hawaii is a diverse place that’s very distinct from other regions of the country. Can you talk a bit about the importance of connection and trust in practicing medicine in a place like Hawaii?

JY: For sure. It doesn’t take long for people to be connected by just a couple of degrees of separation. And what I learned very quickly coming to Hawaii that for so many that health care isn’t just a profession, it really is very personal. We’re caring for neighbors and classmates and teachers and family members. I know that happens everywhere to a degree, but it really happens here in Hawaii. Some statistics that are interesting, Hawaii’s ranked 40th in terms of state population, but I think because of the island state and also because the island of Hawaii is broken up into multiple islands, making those communities even smaller. Folks feel a ton of accountability to each other. Going back to the trust and the relationships are essential to so much of what we do, but they’re especially essential to effective care delivery here on the islands. I know moving from California that I know it takes time for folks from outside of Hawaii to earn and build that trust.

And as a medical group, we spend a great deal of effort onboarding, acculturating our new physicians and clinicians who join us from outside of the state to ensure that they’re successful here. Cultural humility really matters here. Understanding local values, family structures, so many multi-generational households, understanding those traditions aren’t just important. They actually improve outcomes. Our doctors, our physicians, our clinicians are often leaders in the community. They’re not just physicians and clinicians here. Many of our physicians will hold important, valuable, and multiple roles in community organizations.

CG: Every time I have worked in Hawaii and visited members of your team, I understand the connection that they have with the community. And in fact, there’s often stories about school groups, religious groups, community groups, and philanthropic that they’re deeply involved in and that they care about. And it’s far beyond, here’s my patient panel, and it’s all about here is my community that I serve, and that I’m so deeply committed to serving. And every time I leave Hawaii, I leave with a lot of learning. On that note, is there a lesson in community connection that you’ve discovered that might be helpful? We have an audience of physicians and leaders from across the country that might be helpful for them in other parts of the country.

JY: I think some of these things work everywhere, but I think in Hawaii it’s maybe even more valuable and important. The culture here is very much relationships. It’s about getting together. It’s important to invest in these relationships before problems arise. I think as we try to get groups together when there’s a crisis, if we don’t have that foundational relationship, then the trust is not there and we’re not able to work through things as effectively. So we’ve seen the value of that investment upfront sometimes when you don’t even think you need that investment or that relationship just yet.

As an organization, KP Hawaii, and especially within the medical group of HPMG, we spend a lot of energy and effort to bring people together and bring people together in person. We bring them together proactively to create these stronger connections. Even though it’s a small place because we’re separated by water, not all of our team gets to interact with each other on a regular basis.

So we make a point of investing in that as an important foundation for our trust and our accountability to each other. I mean, all of this is super critical in a Permanente model where really exceptional care requires interdisciplinary skills, it requires coordination across multiple specialties, inpatient, outpatient. And I will say listening, understanding what’s happening, following through on your commitments, not just hearing what people are saying, but actually listening and following through on what you commit to are often more important than necessarily having the perfect solution.

Strategies for taking on physician shortages

CG: And I hope our listeners are listening and just that conscientiousness of those steps and those tools is really quite important. Fostering a supportive environment for physicians is a key part of maintaining the workforce that delivers quality care to the communities we serve like Hawaii. And I don’t think I’ve been on a flight or met somebody that was visiting Hawaii that happened to be a physician where I don’t get to know them and actually try to recruit them when I like them into HPMG because I really do believe it’s one of the best places in the entire country to practice. Could you talk about some of the ways the Hawaii Permanente Medical Group works to attract and retain physicians?

JY: It may be a little bit of an unknown fact, but Hawaii faces the worst physician workforce shortage in the country. Sounds very obvious, but visiting and traveling here is very different from living and working here. One thing you’ll find is that our people tend to wear many hats. So people who are comfortable wearing several hats do well. Geography creates a lot of its own unique challenges from limited local training pipelines, distance from professional as well as family networks for our recruits, high cost of living, and all of those things are challenging in Hawaii as a whole, but even more challenging as we get out to our neighbor islands. And some of the work that we’ve done over the last 5 to 10 years that is bringing some long-term success is really a strategy to grow our own where it makes sense. Seeking recruits with some connection to Hawaii tends to make a difference.

We’ve done a lot supporting local students, career shadowing opportunities. We’ve got a key partnership with the medical school here on the island, the University of Hawaii, John A. Burns School of Medicine. A little bit more than 10 years ago, we created an internal medicine residency program that’s been very successful for us. And then just looking for pathways for physicians to return home, either through mentorship, other relationships has also been very vital and critical for us. As I think a little bit about retention, which is the other half of the recruitment, trying to understand why physicians stay. As I’ve witnessed as part of this medical group, it’s really the culture, the purpose, a strong sense of collegiality and connection outside of the usual stuff around compensation, but certainly not the only factor. As a group, we spend a lot of time and investment on physician wellbeing. We have a program that we call SELF CARE that’s very diverse and supportive of our physicians and clinicians.

We spend a lot of energy trying to reduce the administrative burden on them and let them be doctors and physicians and clinicians. And ultimately, I really believe the best recruitment strategy is creating an environment where physicians want to build a life and not just take a job.

Health care innovations overcoming Hawaii’s barriers to access

CG: And for all of our physicians or soon-to-be residency graduates, you heard it here first that there’s a high degree of support and collegiality, wellness programs, and a deep commitment to culture and community that exists in HPMG. And I know it’s way beyond words because I’ve witnessed it, John, under your leadership and with the leadership of the medical group, how deeply committed the group is to each other and to really creating a family. I’m going to move us forward here to talk a bit about access to care through innovation. As we all know, access to preventative care like screening and early detection is vital to improving outcomes and ultimately keeping care affordable. Can you discuss some of the specific barriers to access that are present in local communities and underserved populations? And related to that, what initiatives or innovative digital health tools are you excited about using to overcome some of those barriers?

JY: In many ways, I will say our geography forces us to innovate. We can’t be everywhere. And so I will say innovation’s not optional for us in a way. It’s really how we can ensure patients get access to care regardless of which island they call home. I think being part of a value-based organization allows us to do this in ways that make sense for patients and for our organization and not always have to be driven by how we’re reimbursed. So I think if anybody is set to be able to do this well and do it right, it is an organization like Kaiser Permanente. Things that are pretty normal now, I think we were maybe more on the forefront of pre-COVID, but obviously virtual care, video visits, telehealth, remote patient monitoring, and really any digital tools that help bridge distance. For us, it’s not just innovating for technology’s sake.

It really is with the lens of improving access to people that might be very far away from the expertise that’s needed. Some of the examples I think are pretty commonplace now are virtual specialty consultations. It’s very challenging to have every specialty available physically on all of our islands. Our rural communities are tough to get to, so we do a lot with remote care, remote patient monitoring, anything that allows us to reduce travel for our patients, which can be a barrier, or for our physicians to get out to the different islands, that can impact access as well. And then I think another area that we’ve tried to be really innovative with in a different way is just culturally responsive approaches to care. One of our really proud foundations is our newest West Oahu medical office, and it’s the only Kaiser Permanente facility in the program with a taro garden.
This is a garden that our people are out regularly harvesting and then providing that resource to patients in the communities.
Building care delivery connections before disasters hit

CG: I’ve had the privilege of visiting that garden and working that field alongside you, and it’s an amazing connection to the community and a demonstration of HPMG and Kaiser Permanente’s linkage to the local community. Hawaii has faced serious natural disasters in recent years from fires and flooding to annual threats of hurricanes. I think we have it tough in California. And then I look at Hawaii and what you have dealt with and led through. From a system-wide operations perspective, could you talk about the role Kaiser Permanente played in responding to these many challenges?

JY: Sure, Chris. And just for the record, it’s not a competition for any one of us wanting to be number one in natural disasters, but they are a very real part of life here. And like you mentioned it, hurricanes, flooding, volcanic activity, wildfires, tsunami threats. These aren’t things that might happen. These are all things that have happened and they’ve all happened relatively recently. I think one that most people remember from the very recent past was the Lahaina wildfires. And I will say this level of community trust is especially important during these crises and disasters and public health challenges. And during these Lahaina wildfires, I will say a lot of pride with our ability to respond what I think was very effectively, but I think we were able to do that because of the investment upfront. Our Maui teams had a strong relational culture. They wanted to be on the front lines of care that we were providing immediately after the fires.

Our Oahu teams backed them up for the other clinical work. And I will say this was also a demonstration of amazing support from our Kaiser Permanente enterprise in so many ways. Disaster planning’s more than just about us. This is coordination across multiple health care delivery systems. We had to work with the government, community organization, emergency responders. And I know firsthand if we didn’t have that relationship and trust built beforehand, and I think a lot of that we built during the COVID pandemic, I don’t think we would’ve been as successful in our response. But because we had those relationships, we had that trust, they knew that we were helping for the right reasons, that allowed people to let their guard down and let us in to help them in a way that if we had just come in during the crisis and the wildfires, they may have been more cautious or suspicious of why we were helping.

CG: It comes back to your earlier comments about relationships and building trust in the community long before there’s issues or challenges so that you can work through and really be effective. And I’m always in awe at the positivity and respect in the community in Hawaii that Kaiser Permanente holds. People love the organization, and they also often have a family member that they tell me about that’s a physical therapist or a nurse or a doctor, and they’re very proud of that. Staying in line with responding to natural disasters, it’s not just the community that’s affected, but it’s also the workforce. And I wanted to get a bit of your insight, John, on how you go about preparing physicians, all of our clinicians for disasters on both a personal and a professional level.

JY: It is a very real thing, this idea of workforce resilience and how important it is. As you mentioned, our caregivers are often disaster victims themselves. The health system isn’t just responding to the community, but we’re literally in and a part of those communities. And we had physicians, clinicians, we had staff lose homes in the Lahaina fires, and we mobilized to support them. KP also did something very innovative on Maui, I think people should be aware of, helping to sponsor health care workforce housing on the island. And been an exciting moment, one of our physicians who lost his home in the Lahaina Fires was actually one of the first to be able to live in one of those homes.

The future of health care in Hawaii

CG: Digging deep into that crystal ball, Dr. Yang, what excites you the most about the future of care in general, but also its impact on Hawaii?

JY: After years of seeing both the positive and the challenging impacts of the electronic health record, I’m really excited that technology that enhances rather than replaces, especially that primary care physician-patient relationship. In our organization, we’ve seen how various forms of AI have been fairly quickly implemented and seeing some really positive movement in reducing the administrative burden on our physicians and clinicians with charting, hearing from our physicians that they feel like their attention and focus and time are turned back towards patient care. Lots of technology in other innovations in our specialty, surgical specialties, our surgeons and other specialists are able to do more now with less impact on our patient. A few things that we’ve got in place in Hawaii in the last couple of years, but we’ve really had some amazing advancements and tools that allow us to biopsy parts of the lungs that traditionally were either difficult or impossible to reach.

We’re seeing more complex vascular procedures with advances in fluoroscopy technology. Robotic surgeries just become a part of the way we do business. Our robotic surgeons continue to discover new ways to use our robots at the Moanalua Medical Center, doing procedures that nobody else is able to do here in Hawaii. Another part that I think we have to keep paying attention to besides the technology, but the future workforce, the next generation of physicians, they’re going through one of these sea changes in terms of what people expect out of their physicians. So continuing to invest and develop the next generation of physicians, really investing in creating sustainable practice environments. Super important, especially here in Hawaii where we already have a huge physician shortage. And if people are retiring early because the work is not sustainable, we continue to lose people and worsen that physician shortage problem. Ultimately, I would say what excites me the most is this possibility of giving physicians more time to do what drew them into medicine in the first place, ultimately caring for patients.

CG: That’s beautiful. And I think that is the promise of technology in many ways. And some of the early adoption of electronic medical records and advanced technology probably complicated physicians’ engagement with patients. It might’ve helped from a technical perspective, but the actual kind of face-to-face environment. And now I think the evolution of technology, as you’ve pointed out, whether it’s ubiquitous listening and documentation or advanced diagnostic data analytics capabilities, it just gives more time for that physician to be the mentor, to be the coach, the motivator to that patient that they care so deeply about. John, I can’t tell you how glad I am that when you were called upon in the depths of a pandemic to move yourself and your family to a small island out in the Pacific, that you raised your hand and said yes, because not only are 270,000 patients and members benefiting, but all of the Hawaiian islands.

Your leadership and the team that exists in Hawaii is nothing short of phenomenal. And your informatics background and your understanding of technology allow even one of the most remote and sometimes rural parts of health care to be one of the earliest adopters of some of the most advanced technology. And it’s a combination of creating the right culture and having the right insight. So I thank you for your leadership and for saying yes because it changed the lives of really so many people.

JY: I just want to thank the many people that have supported both myself on a leadership journey as well as the affiliation between Southern California and the Hawaii regions. Our Southern California leadership team has been incredible, very supportive there when we need them, but allowing us to do what is right for the population here in Hawaii. And I have to thank the Hawaii team. It really has been my honor and privilege to be able to serve as the president and medical director for the last five going on 6 years. They really welcomed me with open arms and outsider from California who they occasionally make fun of and force to pronounce difficult Hawaiian words, but I also know that they have embraced me and I couldn’t have done this job without them.

CG: It’s so important that we learn about the diverse stories and health care challenges of the people and practices we serve. There’s always valuable lessons of how value-based care across all of our regions works, and this conversation was no exception. I want to thank you for sharing your insights and for the work you and your team are doing to care for the communities across Hawaii. And I want to thank our listeners to the Permanente Medicine Podcast for tuning in. If you enjoyed this episode, be sure to subscribe, share with your colleagues, and stay tuned for more conversations with physicians and other great leaders shaping the future of health care. Until next time, I’m Chris Grant. Thanks for listening.

The opinions expressed on this podcast are those of the speakers and are not necessarily the views of Kaiser Permanente, the Permanente Medical Groups, or the Permanente Federation.

The post Inside Hawaii’s community-driven approach to health care appeared first on Permanente Medicine.

Introduction: The First Question Is Not What You Billed, It Is Who Is Asking

When an audit letter arrives at a medical practice, the instinctive response is to start pulling charts. That instinct is understandable and it is also premature. Before a single record is retrieved, someone in the practice needs to answer a more consequential question: which contractor sent this letter, and what authority does that contractor actually have?

The answer determines almost everything that follows. It determines how many days you have to respond, whether that deadline is 30 or 45. It determines whether the reviewer is looking at claims already paid or holding future payments hostage. It determines whether the worst realistic outcome is a modest repayment demand or a seven-figure extrapolated liability. And it determines whether you are dealing with a routine payment-integrity review or the front end of a fraud investigation that may be referred to the Department of Justice.

Medicare program integrity work is distributed across a set of contractors with genuinely different mandates. A Medicare Administrative Contractor conducting a routine prepayment review and a Unified Program Integrity Contractor investigating suspected fraud will both send you a request for medical records. The letters look similar. The consequences are not remotely similar. Practices that treat every records request the same way routinely underreact to the dangerous ones and overreact to the routine ones.

This guide maps all seven audit types a physician practice is likely to encounter. For each, it covers who the contractor is, what authority it holds, what triggers its interest, how long you have to respond, how far back it can look, whether it can extrapolate, and what the realistic downside looks like. It closes with a practical guide to identifying which audit you are facing from the letter itself, and the first five actions to take once you know.

Why Contractor Identity Determines Your Exposure

Four variables separate a manageable audit from a practice-threatening one. Each of them is a function of which contractor is involved.

Response Deadline

Most contractors allow 45 calendar days to produce records. UPICs allow 30. That fifteen-day difference matters enormously when the request covers dozens of claims across multiple years and the records live in more than one system. Practices that assume they have 45 days when they actually have 30 lose the case before it starts, because an unanswered documentation request is not a neutral event. It converts to a denial, and the denial converts to an overpayment.

Payment Posture

Prepayment review means claims are held before payment. Cash flow stops immediately and stays stopped for the duration of the review. Post-payment review means the contractor is examining money you have already received and spent, and will demand it back. Both are serious. They are serious in completely different ways, and they call for different operational responses.

Extrapolation Authority

Some contractors may project the error rate found in a small sample across the entire universe of comparable claims. This is the single largest driver of catastrophic audit exposure. An error rate of eleven percent found in a forty-claim sample can become a demand measured in seven figures once projected across three years of billing. Whether the contractor reviewing your claims has this authority is the most financially significant question in the entire process.

Enforcement Referral Risk

Most contractors are looking for improper payments. UPICs and the OIG are looking for fraud. A UPIC can conduct unannounced site visits, interview staff, suspend payments, and refer a matter to the OIG or the Department of Justice. When that contractor is involved, the exposure is not merely financial and the response should involve counsel from the outset.

Audit Type 1: Medicare Administrative Contractors (MACs)

MACs are the regional contractors that process Medicare fee-for-service claims. Your practice already interacts with a MAC constantly, because the MAC is who you bill. Beyond claims processing, MACs conduct medical review to ensure claims meet coverage, coding, and documentation requirements.

Authority and Scope

MACs conduct both prepayment and post-payment review within their jurisdiction. Prepayment review is the more operationally disruptive of the two, because claims subject to review are held before payment rather than paid and later recovered. A practice placed on prepayment review experiences an immediate interruption in cash flow that continues until the review is lifted.

Response Deadline

45 calendar days from the date printed on the additional documentation request. The regulatory basis is 42 CFR 405.903 for prepayment review and 42 CFR 405.929 for post-payment review.

Typical Triggers

• A claim trips a service-specific edit or fails an automated coverage check
• Billing patterns that deviate from local coverage determination expectations
• Selection for a targeted probe based on error-rate data
• A referral downstream from another contractor’s findings

Realistic Exposure

For a limited prepayment review, exposure is primarily operational: delayed payment on the claims under review and the administrative cost of responding. For a broader post-payment review, exposure is the value of denied claims plus the risk that findings escalate to a larger review. MACs also administer the demand and recoupment process for findings generated by other contractors, so the MAC is frequently the entity that ultimately sends the bill even when it did not conduct the review.

Audit Type 2: Targeted Probe and Educate (TPE)

TPE is a MAC-administered program, but it functions distinctly enough to warrant separate treatment. It is also the audit a typical physician practice is most likely to encounter, and the one most commonly mishandled.

How TPE Works

TPE is structured as an educational intervention rather than a pure recovery action. The MAC selects a small sample of claims, generally twenty to forty, reviews them, and then offers one-on-one education addressing the errors found. The practice then has a correction window of roughly 45 days before the next round begins.

The program runs up to three rounds. A practice that demonstrates sufficient improvement can exit after Round 1 or Round 2 and return to normal claims processing. A practice that does not improve proceeds to the next round.

Why Round 3 Matters So Much

Failure to achieve compliance after three rounds is the point at which TPE stops being educational. CMS may then refer the practice for 100 percent prepayment review, authorize extrapolation, refer the matter to a Recovery Audit Contractor, or pursue other administrative action. Any of these outcomes is materially worse than the TPE itself.

This structure creates an unusual dynamic. TPE is simultaneously the most forgiving audit in the Medicare program and the gateway to the least forgiving ones. The practices that fare worst are those that treat Round 1 as a formality, submit records without reviewing them, and discover in Round 2 that the same documentation deficiencies are still present.

Response Deadline

45 calendar days for the documentation request, followed by a correction period of approximately 45 days between rounds.

The Strategic Insight

The correction window between rounds is the most valuable and most underused asset in the entire TPE process. It exists specifically so the practice can fix what the MAC identified. Practices that use it to conduct an internal audit of the same service line, retrain the providers responsible for the deficient documentation, and verify the fix before the next round begins routinely exit at Round 2. Practices that treat the education session as a box to check tend to see Round 3.

Audit Type 3: Recovery Audit Contractors (RACs)

RACs are the contractors most providers have heard of, and their defining feature is their compensation structure.

The Contingency Fee Structure

RACs are paid a percentage of what they recover. This is not a criticism of individual reviewers so much as a structural fact that providers should understand: the program is designed to find overpayments, and the entity conducting the review has a direct financial interest in finding them. That structure informs how findings should be scrutinized and how readily they should be accepted.

Look-Back Period and Documentation Limits

RAC review volume is governed by additional documentation request limits tied to the provider’s claim volume. The baseline annual ADR limit is calculated as a percentage of the provider’s total paid Medicare claims from the prior twelve-month period, and that annual figure is divided into eight cycles, establishing the maximum number of claims that can be requested in any single 45-day period. RACs may not issue requests more frequently than every 45 days.

The look-back period is linked to which limit the RAC elects to use. A RAC reviewing under the baseline annual ADR limit may look back three years from the claim paid date. A RAC reviewing under an adjusted ADR limit, which applies to providers with elevated denial rates, works from a shorter six-month look-back. Denial rates are recalculated after three 45-day cycles, and favorable appeal outcomes are factored into that recalculation.

Response Deadline

45 calendar days for the documentation request.

The Discussion Period

When a RAC notifies a provider of overpayment findings, a discussion period opens during which the provider may submit additional documentation and argue for reversal directly to the RAC, before the finding is referred to the MAC for recoupment. Each RAC administers its own discussion process and publishes the procedure on its website.

Two features of the discussion period are frequently misunderstood. First, it is not an appeal. Contacting the RAC does not preserve appeal rights, does not stop interest from accruing, and does not extend the deadline to request redetermination. Second, once a provider requests redetermination from the MAC, the discussion option closes. The two paths cannot be pursued simultaneously, which makes sequencing a genuine strategic decision rather than an administrative detail.

Extrapolation Authority

CMS permits Recovery Auditors to use extrapolation in defined circumstances, including providers who maintain a high denial rate over an extended period, providers with excessively high denial rates over a shorter period, and providers with a moderate denial rate whose improper payments nonetheless total a significantly high dollar amount. This is the mechanism by which a RAC review of forty claims becomes a demand across three years of billing.

Audit Type 4: Unified Program Integrity Contractors (UPICs)

A UPIC letter is the most serious routine correspondence a medical practice can receive from a Medicare contractor.

UPICs consolidated the functions of earlier program integrity contractors into single entities responsible for both Medicare and Medicaid across five regions. Their mandate is not payment accuracy. It is fraud, waste, and abuse.

Authority and Scope

UPICs are authorized to identify program vulnerabilities, proactively detect potential fraud within their service area, investigate allegations of fraud, develop fraud leads, initiate administrative actions including payment suspensions and enrollment revocations where reliable evidence of fraud exists, and refer providers for further action. They may conduct unannounced site visits and interview staff. They also review both pre-payment and post-payment.

Notably, UPICs are statutorily tasked with identifying underpayments as well as overpayments, a point that occasionally becomes relevant in defending against a one-sided review.

Response Deadline

30 calendar days, not 45. This is the shortest response window among the major contractors and the single most common deadline error practices make. A practice that calendars 45 days on a UPIC request has already lost fifteen days it did not have.

Realistic Exposure

Payment suspension, enrollment revocation, extrapolated overpayment demands, and referral to the OIG or Department of Justice. A UPIC investigation can develop into a False Claims Act matter. The financial exposure is real, but the enforcement exposure is what distinguishes a UPIC from every other contractor on this list.

Practical Guidance

When a UPIC letter arrives, engage healthcare counsel before responding, not after. The records submitted in response to a UPIC request may become evidence in a subsequent enforcement proceeding, and decisions about scope, privilege, and supplemental documentation should be made with that possibility in view. This is materially different from the posture appropriate to a routine MAC probe.

Audit Type 5: Supplemental Medical Review Contractor (SMRC)

The SMRC conducts nationwide medical review as directed by CMS, rather than operating within a geographic jurisdiction. Reviews cover Medicare Part A, Part B, and durable medical equipment, prosthetics, orthotics, and supplies.

How SMRC Reviews Are Selected

SMRC reviews are issue-driven rather than provider-driven. CMS identifies a service category or provider specialty presenting elevated improper payment risk, and the SMRC reviews claims in that category nationally. Selection inputs include CMS internal data analysis, CERT program findings, professional organization input, and recommendations from federal oversight agencies.

The practical implication is that an SMRC review is often not a judgment about your practice specifically. You may have been selected because you bill a service category that CMS has flagged nationally. That context is worth understanding, though it does not reduce the importance of the response.

Response Deadline

45 calendar days.

Realistic Exposure

Denial of reviewed claims and referral of findings to the MAC for recoupment. SMRC findings can also inform subsequent contractor activity, so a poor outcome may have downstream consequences beyond the claims at issue.

Audit Type 6: Comprehensive Error Rate Testing (CERT)

CERT is structurally different from every other audit on this list, and the difference is worth understanding because it changes the appropriate response.

Purpose

CERT exists to measure the national improper payment rate for the Medicare fee-for-service program. Claims are selected randomly. The program is a statistical measurement exercise, not a targeted enforcement action, and selection carries no implication that your billing was flagged.

Why It Still Matters

Two reasons. First, if the documentation you submit does not support the claim, the claim is still denied and the payment is still recovered. Random selection does not confer immunity. Second, and more significantly, CERT findings feed the national improper payment data that CMS uses to direct other contractors. A service category with a high CERT error rate becomes a target for SMRC review and RAC activity. Your individual CERT response contributes to that dataset.

Response Deadline

45 calendar days from the date of the letter.

The Most Common CERT Mistake

Practices frequently deprioritize CERT requests precisely because they are random and the individual dollar amounts are small. The result is incomplete submissions that generate insufficient-documentation denials. Those denials are recovered from the practice and they inflate the national error rate for that service, which invites further scrutiny of every practice billing it. A CERT request deserves the same documentation rigor as any other.

Audit Type 7: HHS Office of Inspector General (OIG)

The OIG is not a CMS contractor. It is the independent oversight arm of the Department of Health and Human Services, and its involvement signals a different category of matter entirely.

Authority and Scope

The OIG conducts audits, evaluations, and investigations of HHS programs. It holds subpoena power, coordinates with the Department of Justice on civil and criminal healthcare fraud enforcement, and administers program exclusion. It also publishes the annual Work Plan identifying the specific audit and enforcement priorities the agency intends to pursue, which is the closest thing providers have to advance notice of where federal attention is headed.

How OIG Involvement Typically Arises

• Referral from a UPIC or other contractor following a program integrity investigation
• A qui tam relator complaint filed under the False Claims Act
• Data analytics identifying billing patterns consistent with known fraud schemes
• A Work Plan initiative targeting the provider’s specialty or service line
• Voluntary self-disclosure by the provider through the OIG Self-Disclosure Protocol

Realistic Exposure

Civil monetary penalties, False Claims Act liability including treble damages and per-claim penalties, corporate integrity agreement obligations, program exclusion, and in cases involving criminal conduct, prosecution. This is not an audit in the sense that the other six are audits, and it should never be handled without experienced counsel.

Side-by-Side Comparison: Deadlines, Look-Back Periods, and Authority

The following summary consolidates the operative differences among the seven audit types.

Response Deadlines

• 30 calendar days: UPIC
• 45 calendar days: MAC, TPE, RAC, SMRC, CERT
• Varies by instrument: OIG, which may proceed by subpoena or civil investigative demand with its own timeline

Payment Posture

• Prepayment or post-payment: MAC, TPE, UPIC
• Post-payment: RAC, SMRC, CERT
• Investigative rather than claims-based: OIG

Extrapolation Authority

• Yes, under defined conditions: RAC, UPIC, and MACs following TPE failure
• Generally no: CERT, which measures rather than recovers at scale
• Uses statistical methods in a different posture: OIG, including within the Self-Disclosure Protocol damage calculation

Enforcement Referral Risk

• High: UPIC, OIG
• Moderate, generally through escalation: MAC following repeated TPE failure
• Lower, primarily financial: RAC, SMRC, CERT

What Triggers Each Type of Audit

Understanding what draws contractor attention allows a practice to monitor its own exposure before a letter arrives.

Data-Driven Triggers

• Billing volume for a specific code or modifier that places the provider in an outlier percentile relative to specialty peers
• Evaluation and management coding distribution skewed toward the highest levels
• Modifier 25 usage rates substantially above specialty norms
• Sudden changes in billing patterns, particularly volume increases in a single service line
• Referral or ordering patterns inconsistent with peer behavior

Event-Driven Triggers

• Prior contractor findings, since a RAC overpayment determination or CERT sample finding can produce a downstream review
• A qui tam complaint referred for billing analysis support
• Beneficiary or employee complaints
• Specialty-specific enforcement initiatives targeting a service category
• OIG Work Plan items covering the provider’s services

Random Selection

CERT alone selects randomly. Every other audit type on this list involves some form of targeting, whether provider-specific or service-category-specific. If you are facing anything other than a CERT review, something identified you.

Extrapolation: The Factor That Changes Everything

No other variable affects the financial magnitude of an audit as much as whether extrapolation is applied.

The mechanics are straightforward. The contractor reviews a sample of claims, calculates an error rate, and projects that rate across the full universe of comparable claims within the look-back period. A practice with 4,000 comparable claims over three years that shows a fifteen percent error rate in a forty-claim sample does not owe the value of six denied claims. It faces a demand calculated across roughly 600 projected claims.

What most providers do not know is that extrapolation methodology is challengeable, and that a successful challenge reduces liability to the actual overpayment identified in the sample rather than the projected amount. The difference is routinely the difference between a manageable repayment and an existential one.

Grounds for challenge include defects in how the universe of claims was defined, improper stratification, inadequate precision in the estimate, application of variable appraisal methodology to what are actually binary determinations, systematic bias where sample means exceed universe parameters, and misapplication of sampling software to highly skewed or low-variance claim populations.

An OIG review of the appeals process found that Medicare contractors were not consistent in how they reviewed extrapolated overpayments during provider appeals, and recommended that CMS provide additional guidance to improve consistency. That inconsistency is precisely why methodology challenges succeed with meaningful frequency, and why the Administrative Law Judge level of appeal is where extrapolation is most often defeated.

Challenging extrapolation requires statistical expertise, not merely coding expertise. This is a distinct discipline, and it is addressed in depth in the companion article in this series on statistical extrapolation in Medicare audits.

How One Audit Becomes Another: Escalation Pathways

Audits do not exist in isolation. Findings flow between contractors, and a small review handled poorly can produce a much larger one.

The Common Escalation Sequences

• TPE to prepayment review or RAC referral. Three failed TPE rounds can result in 100 percent prepayment review, authorized extrapolation, or referral to a Recovery Audit Contractor.
• CERT to SMRC. Elevated CERT error rates in a service category prompt CMS to direct nationwide SMRC review of that category.
• RAC to UPIC. A RAC overpayment determination showing a pattern rather than isolated errors can prompt program integrity referral.
• UPIC to OIG or DOJ. Where a UPIC develops reliable evidence of fraud, the matter moves from administrative recovery to enforcement.
• Any audit to False Claims Act exposure. Findings that establish the provider knew or should have known claims were improper, particularly where prior audit findings were not remediated, support the FCA knowledge standard.

The Remediation Point

The through-line in every escalation sequence is unremediated findings. A first audit that identifies a documentation deficiency is a problem. The same deficiency still present at the second audit is evidence. Practices that treat audit findings as a correction mandate rather than a cost of doing business break the escalation chain at its first link.

Reading Your Audit Letter: A Practical Identification Guide

Use the following to identify what you are facing within the first few minutes.

Check the Letterhead and Contractor Name

The contractor’s name appears on the letterhead. If it matches the MAC that processes your claims, you are dealing with MAC medical review or TPE. If it is a name you do not recognize, identify it before proceeding, since RACs, UPICs, and the SMRC operate under contractor names distinct from your MAC.

Look for Program Identification Language

• References to Targeted Probe and Educate, rounds, or an offer of one-on-one education indicate TPE
• References to the Recovery Audit Program or a discussion period indicate a RAC
• References to program integrity, investigation, or an unusually short response window indicate a UPIC
• References to a nationwide review of a specific service category indicate the SMRC
• References to measuring the improper payment rate indicate CERT

Note the Response Deadline

A 30-day window is a strong indicator of a UPIC. Calendar the deadline from the date printed on the letter, not the date it was received or opened.

Determine Prepayment or Post-Payment

Language indicating claims are being held pending review signals prepayment. Language referring to claims already paid, or an overpayment determination, signals post-payment.

Look for Extrapolation Language

References to statistical sampling, an overpayment estimate, a universe of claims, or a projected amount indicate extrapolation is in play. This changes the required response and generally warrants immediate expert involvement.

The First Five Actions After an Audit Letter Arrives

• Identify the contractor and calendar the deadline from the letter date. Confirm whether the window is 30 or 45 days. Build the internal schedule backward from the deadline with a submission target at least five business days early.
• Determine whether enforcement risk is present. If the letter is from a UPIC or the OIG, or if it references investigation rather than payment review, engage healthcare counsel before producing anything.
• Preserve everything. Implement a documentation hold covering the claims at issue and the surrounding period. Do not alter, append to, or reorganize records after receiving notice. Late additions to a record are among the most damaging findings an auditor can make.
• Audit the requested claims internally before submitting. Review each claim against the documentation as an auditor would. Knowing your own exposure before the contractor does determines whether you are managing the process or reacting to it.
• Decide on scope and supplemental documentation. Determine what the request actually requires, whether supporting records from other sources belong in the package, and whether a position paper explaining medical necessity should accompany the submission.

The mechanics of executing steps three through five are covered in detail in the companion article in this series on responding to a Medicare records request.

How DoctorsManagement Defends Practices Across Every Audit Type

DoctorsManagement has represented physician practices, group practices, health systems, ambulatory surgery centers, and federally qualified health centers through every category of Medicare and commercial payer audit. Our audit defense team combines credentialed coding and auditing expertise with statistical and economic analysis, which is the combination these matters actually require.

Our auditors hold both the Certified Professional Coder and Certified Professional Medical Auditor credentials and receive ongoing training through NAMAS, our education division. For matters involving extrapolation, we bring statisticians and economists who can evaluate sampling methodology on its own terms.

Our audit-related services include:

• Audit Response Management: Review of the documentation request, internal pre-submission audit of the claims at issue, and preparation of a complete, defensible response package
• Extrapolation Defense: Statistical analysis of contractor sampling methodology, identification of methodological defects, and expert support for challenges at every appeal level
• Appeal Representation: Preparation and prosecution of redetermination, reconsideration, and ALJ-level appeals, including medical necessity argumentation and clinical expert support
• Coding and Documentation Review: Independent assessment of coding accuracy and documentation sufficiency, both as audit defense and as remediation to prevent escalation
• Litigation Support and Expert Witness Services: Testifying expertise on coding, documentation, medical necessity, and statistical methodology where matters proceed to hearing or litigation
• Post-Audit Remediation: Corrective action planning, provider training, and compliance program strengthening to break the escalation chain

If your practice has received an audit letter, contact DoctorsManagement at www.doctorsmanagement.com/audit-appeal-defense or call (800) 635-4040. Early involvement produces materially better outcomes than engagement after findings are issued.

Frequently Asked Questions

How do I tell which type of Medicare audit I am facing?

Start with the contractor name on the letterhead and the response deadline. A 30-day window strongly suggests a UPIC. References to rounds and one-on-one education indicate TPE. References to the Recovery Audit Program or a discussion period indicate a RAC. Language about measuring the improper payment rate indicates CERT. A nationwide review of a specific service category indicates the SMRC.

How long do I have to respond to a Medicare records request?

45 calendar days for MAC, TPE, RAC, SMRC, and CERT requests, and 30 calendar days for UPIC requests. The clock runs from the date printed on the letter, not the date your practice received or opened it. Contractors may grant good cause extensions for documented extenuating circumstances, but the request must reach the contractor before the deadline passes.

Which audits can use extrapolation?

RACs may extrapolate under defined conditions involving elevated denial rates or significant improper payment dollar amounts. UPICs may extrapolate. MACs may extrapolate following TPE failure. CERT is a measurement program and does not extrapolate against individual providers in the same manner. Extrapolation is the single largest driver of catastrophic audit exposure, and its methodology is challengeable.

What is the difference between a RAC audit and a UPIC audit?

A RAC is a financial recovery program paid on contingency and focused on identifying improper payments. A UPIC is a program integrity contractor investigating fraud, waste, and abuse. UPICs can conduct unannounced site visits, interview staff, suspend payments, revoke enrollment, and refer matters to the OIG or Department of Justice. The RAC risk is primarily financial. The UPIC risk includes enforcement.

What happens if I fail all three rounds of TPE?

CMS may refer the practice for 100 percent prepayment review, authorize extrapolation, refer the matter to a Recovery Audit Contractor, or pursue other administrative action. Each of these outcomes is significantly worse than the TPE itself, which is why the correction window between rounds should be used for genuine internal auditing and provider retraining rather than treated as a formality.

Should I be worried about a CERT audit if selection is random?

You should respond to it with full rigor. Random selection does not protect you: if the documentation does not support the claim, the claim is denied and the payment is recovered. CERT findings also feed the national improper payment data that CMS uses to direct RAC and SMRC activity, so incomplete responses contribute to increased scrutiny of the entire service category.

When should I involve an attorney in an audit?

Immediately for any UPIC or OIG matter, any matter referencing investigation rather than payment review, and any matter involving extrapolation with significant dollar exposure. For routine MAC probes, TPE Round 1, and CERT requests, experienced audit defense consultants are often sufficient, though counsel should be consulted if findings suggest a pattern or if the matter escalates.

Can an audit lead to False Claims Act liability?

Yes. The FCA knowledge standard encompasses reckless disregard and deliberate ignorance, not merely actual knowledge. Audit findings that a practice failed to remediate can establish that the practice knew or should have known claims were improper. This is why unaddressed audit findings are substantially more dangerous than the findings themselves.

How far back can a Medicare audit go?

It depends on the contractor and the review posture. RACs reviewing under the baseline annual ADR limit may look back three years from the claim paid date, while those reviewing under an adjusted ADR limit work from a six-month look-back. UPIC and OIG matters involving suspected fraud can reach further, and False Claims Act limitations periods extend well beyond typical audit look-back windows.

How can DoctorsManagement help with a Medicare audit?

DoctorsManagement provides audit response management, extrapolation defense with statistical and economic expertise, appeal representation through all five levels, coding and documentation review, litigation and expert witness support, and post-audit remediation. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• CMS Medicare Overpayments Fact Sheet (MLN006379)
• CMS Medicare Financial Management Manual, Chapter 4: Debt Collection
• CMS Regulations and Guidance
• OIG Report: Medicare Contractors Were Not Consistent in How They Reviewed Extrapolated Overpayments
• OIG Work Plan
• OIG Fraud and Abuse Laws for Physicians
• OIG Self-Disclosure Information
• ACEP Recovery Audit Contractor (RAC) FAQ
• DoctorsManagement Audit Appeal and Defense
• DoctorsManagement Healthcare Compliance Audit
• DoctorsManagement Coding and Documentation Review
• DoctorsManagement Total Compliance Solution

Contact Us

This article is provided for informational and educational purposes only and does not constitute legal advice. Audit procedures, deadlines, and contractor authorities are subject to change, and the appropriate response to any specific audit depends on its particular facts. Practices facing an audit should consult qualified legal and compliance professionals. DoctorsManagement is available to provide audit defense consulting and can assist practices at any stage of the audit and appeal process.

The post The 7 Types of Medicare Audits Explained: RAC, MAC, UPIC, CERT, SMRC, TPE, and OIG appeared first on DoctorsManagement.

Introduction: The Phase Most Practices Treat as Clerical

A Medicare contractor sends a request for medical records. Someone in the practice pulls the charts, prints what the letter asks for, and mails the package. The task feels administrative, so it gets assigned accordingly, often to whoever has capacity that week.

This is the most consequential misjudgment a practice makes in the entire audit lifecycle.

The documentation you submit in response to that request becomes the complete evidentiary record for every stage that follows. The contractor’s determination will be based on it. The redetermination will be based on it. The reconsideration will be based on it. By the time a matter reaches an Administrative Law Judge, the practice is arguing about the sufficiency of a package assembled months earlier by someone who did not know they were building a litigation record.

The asymmetry here is stark. A thorough, well-organized, internally audited response costs the practice a few dozen hours. A rushed or incomplete one produces denials that convert to overpayment demands, and those demands can be extrapolated across years of billing. The practices that fare best in Medicare audits are almost never the ones with perfect documentation. They are the ones that took the response phase seriously.

This guide covers the first thirty to forty-five days after a records request arrives: what to do, in what order, and which decisions carry consequences that persist through every subsequent appeal level.

What an Additional Documentation Request Actually Is

The additional documentation request, commonly called an ADR, is the instrument a Medicare contractor uses to pull the medical record behind a claim before deciding whether that claim survives review. Medicare Administrative Contractors, Recovery Audit Contractors, Unified Program Integrity Contractors, and the Supplemental Medical Review Contractor can all issue one.

Every ADR tests a single question: does the medical record support the claim as billed, including medical necessity under the applicable coverage determination? Everything about your response should be organized around answering that question affirmatively and making it easy for the reviewer to see the answer.

Why the Request Was Sent

MACs typically issue ADRs during prepayment or post-payment medical review when a claim trips a service-specific edit or the provider has been selected for a targeted probe. RACs and UPICs generally pull claims post-payment based on data analysis flagging billing patterns rather than any single claim. The distinction matters because it tells you whether the contractor is examining one service or a pattern across your billing.

What a Non-Response Produces

An unanswered ADR is not a neutral outcome. The claim is denied for insufficient documentation, the denial produces an overpayment, and the overpayment enters the demand and recoupment process. A late or incomplete response frequently becomes the opening move of a larger post-payment audit, because a documentation failure across a sample suggests a documentation problem across the population.

Day One: Calendar the Deadline Correctly

The response clock starts on the date printed on the ADR letter, not the date your practice opens the mail.

This single point costs practices more days than any other. Mail transit, internal routing, and the time a letter sits in an unopened stack all consume the response window. A letter dated the first of the month that reaches the compliance officer on the twelfth has already burned a quarter of the available time.

The Deadlines

• 45 calendar days: MAC, RAC, and SMRC requests
• 30 calendar days: UPIC requests

The regulatory basis is 42 CFR 405.903 for prepayment review and 42 CFR 405.929 for post-payment review. Note that these are calendar days, not business days.

Build the Schedule Backward

Set the internal submission target at least five business days before the actual deadline. That buffer absorbs the problems that reliably surface late in the process: a record that cannot be located, an imaging report held by an outside facility, a signature that was never captured, a provider who is on vacation the week the package needs review.

From the submission target, work backward to establish milestones for claim inventory completion, internal audit completion, and package assembly. A 45-day window is adequate. A 45-day window discovered on day 20 is not.

Days One to Three: Identify the Contractor and Assess Enforcement Risk

Before producing anything, determine who is asking and what category of matter this is. The contractor name appears on the letterhead. If it is not the MAC that processes your claims, identify the entity before proceeding.

The Threshold Question

Is this a payment review or an investigation?

Payment reviews, meaning most MAC, RAC, SMRC, and CERT activity, are about whether specific claims were properly paid. Investigations, meaning UPIC and OIG matters, are about whether the provider engaged in fraud, waste, or abuse. The records you produce in an investigation may become evidence in a subsequent enforcement proceeding.

When to Engage Counsel Before Responding

• The request comes from a UPIC or the OIG
• The letter references investigation, program integrity, or potential fraud rather than payment review
• The request is accompanied by a subpoena or civil investigative demand
• The response window is 30 days rather than 45
• The request references statistical sampling, a universe of claims, or an overpayment estimate
• Your internal review suggests the claims at issue have genuine documentation problems across a pattern

In these situations, decisions about scope, privilege, and supplemental documentation should be made with counsel before the package is assembled, not after findings are issued.

Days One to Three: Implement a Documentation Hold

Immediately upon receiving an audit notice, implement a hold covering the claims at issue and the surrounding period. The hold should prevent deletion, alteration, or reorganization of relevant records, including the electronic health record, billing system data, scheduling records, correspondence, and any related communications.

Why This Matters More Than It Appears To

Electronic health records maintain audit trails. Every access, every edit, and every addendum is timestamped. A reviewer examining a record can generally determine when each element was created and whether anything was added after the encounter.

A documentation entry created after the audit notice arrived, appearing in a record submitted in response to that notice, is among the most damaging findings possible. It converts a documentation deficiency, which is a payment issue, into an apparent falsification, which is an enforcement issue. Practices have turned recoverable audits into False Claims Act exposure through well-intentioned late edits.

What the Hold Should Cover

• Clinical documentation for the claims under review
• Clinical documentation for the same patients in the surrounding period, since context frequently matters to medical necessity
• Billing and claims data, including submission histories and remittance advices
• Scheduling and registration records
• Orders, referrals, and results from outside entities
• Internal correspondence regarding the claims or services at issue
• Prior audit findings and any related corrective action documentation

Days Three to Ten: Build the Claim Inventory

Create a working inventory of every claim in the request. For each, capture the beneficiary identifier, date of service, claim number, CPT and HCPCS codes billed, diagnosis codes, modifiers, rendering provider, place of service, and paid amount.

This inventory becomes the control document for the entire response. It tracks which records have been located, which are complete, which have identified problems, and which have been included in the package.

Locate Every Component

Clinical documentation for a single encounter frequently lives in more than one place. Depending on the service, a complete record may require:

• The encounter note, including history, examination, and medical decision making
• Physician orders and the documentation supporting medical necessity for those orders
• Diagnostic test results and interpretations, which may be held by an outside facility
• Operative or procedure notes
• Nursing and ancillary staff documentation
• Medication administration records
• Signed advance beneficiary notices where applicable
• Referral documentation and prior authorization records
• Physician signature and credentials, including signature attestations where a signature is illegible or missing

Start Outside Requests Immediately

Records held by outside entities, meaning hospital records, imaging center reports, reference laboratory results, and prior treating physician documentation, take time to obtain. Submit those requests in the first week. Waiting until the internal record review is complete is the most common cause of missed deadlines.

Days Five to Twenty: Audit Your Own Claims Before Submitting

This is the step that separates practices that manage audits from practices that are managed by them.

Before submitting anything, review each requested claim exactly as the contractor will. Evaluate whether the documentation supports the level of service billed, whether medical necessity is established under the applicable coverage determination, whether modifiers are supported, whether signatures and dates are present and legible, and whether every billed element appears in the record.

Why Do This

Three reasons, each independently sufficient.

First, it tells you what is coming. A practice that knows its own error rate before submission can plan for the findings, budget for the exposure, and prepare the appeal strategy in advance rather than reacting to a demand letter.

Second, it identifies documentation that exists but was not going to be included. Reviewers deny claims for missing elements that were actually documented elsewhere in the chart and simply never made it into the package. A pre-submission audit catches these.

Third, and most significantly, it reveals whether the problem is isolated or systemic. If the sample shows a pattern, the practice has an obligation to consider whether that pattern extends beyond the claims under review, and whether the sixty-day overpayment rule is implicated for claims the contractor has not yet examined. Discovering this after the audit concludes is substantially worse than discovering it during the response window.

Who Should Conduct It

Not the person who coded the claims. Self-review by the coder or provider responsible for the original documentation reliably produces optimistic assessments. Use a credentialed auditor without prior involvement in the claims at issue, whether internal to the practice or engaged externally.

What to Do With Bad News

If the internal audit reveals genuine deficiencies, that information is valuable rather than merely unwelcome. It informs whether to pursue the discussion period with a RAC, whether to prepare for appeal, whether to engage counsel, and whether a broader internal review or voluntary disclosure warrants consideration. What it does not justify is altering the records.

What a Complete Response Package Contains

Organize the submission so a reviewer can evaluate each claim without hunting for anything. The reviewer’s job is to determine whether documentation supports the claim. Anything that makes that determination harder works against you.

Package Structure

• Cover letter. Identify the practice, the contractor’s request by reference number, the claims included, the date of submission, and the contact person for questions. State plainly that the enclosed records are complete for each claim.
• Index or table of contents. List each claim by beneficiary, date of service, and claim number, with corresponding page numbers or tab identifiers.
• Claim-by-claim sections. Separate each claim clearly. Within each section, present documentation in a consistent order across all claims so the reviewer learns the structure once.
• Signature attestations where required. Where a signature is illegible or absent from an otherwise complete record, include a properly executed attestation statement.
• Supporting policy documentation where relevant. Where medical necessity turns on a coverage determination, including the applicable policy language can help the reviewer connect the documentation to the standard.

Practical Requirements

• Every page legible. Illegible documentation is treated as absent documentation
• Every page attributable to a specific patient and date of service
• Complete records rather than excerpts, unless the request specifies otherwise
• Submitted by the method the contractor specifies, whether electronic portal, fax, or mail
• A complete copy of everything submitted retained by the practice, exactly as sent
• Proof of timely submission retained, including transmission confirmations or certified mail receipts

Retain What You Sent

The retained copy is not a formality. If the matter proceeds to appeal, you will need to demonstrate precisely what the contractor received. Disputes about whether a document was included in the original submission are common and are resolved in favor of the party with the better record.

The Amendment Question: When Correcting the Record Helps and When It Destroys You

This question arises in nearly every audit and is answered incorrectly with alarming frequency.

The Rule

Medical records may be amended, corrected, or supplemented through legitimate documentation practices. A legitimate amendment is clearly identified as an amendment, is dated as of the date it was actually made, identifies the individual making it, and does not obscure the original entry. Electronic systems generally handle this automatically through addendum functionality.

What is never acceptable is altering a record to make it appear that documentation existed at the time of service when it did not. Backdating, overwriting original entries, or creating documentation after an audit notice and presenting it as contemporaneous crosses from documentation practice into falsification.

The Practical Standard

Ask whether the amendment adds a legitimate, clearly dated clarification, or whether it attempts to cure a deficiency by making the record look different than it did when the audit notice arrived. The first is defensible. The second is not, and the EHR audit trail will reveal it.

Timing Considerations

An amendment made after an audit notice, even a legitimate one, will draw scrutiny. Reviewers examine timestamps precisely because late documentation is a known indicator. Where a legitimate post-notice amendment is necessary, it should be clearly identified, properly dated, and ideally accompanied by an explanation in the cover letter rather than left for the reviewer to discover.

Signature Attestations

Missing or illegible signatures are a distinct and more forgiving category. Where the documentation is otherwise complete but the signature is illegible or was not captured, a signature attestation statement is an accepted remedy. The attestation confirms the identity of the author and that the author provided the documented service. It does not add clinical content, which is why it does not carry the risk that substantive amendment does.

Should You Include a Position Paper?

A position paper is a written explanation submitted alongside the records, framing why the claims meet coverage and medical necessity requirements. It is optional and it is not always advisable.

When It Helps

• The medical necessity rationale is clinically sound but not obvious from the face of the record
• The patient presentation was atypical in a way that justifies the service billed
• The applicable coverage determination contains ambiguity that the documentation resolves
• Documentation supporting the claim is distributed across multiple sources and the connections benefit from explanation
• The practice’s patient population differs from the norm in ways that explain apparent outlier billing

When It Hurts

• The documentation genuinely does not support the claim, in which case the paper draws attention to the gap and may constitute an admission
• The explanation relies on facts not present in the medical record
• The matter carries enforcement risk, where written statements may be used in a subsequent proceeding
• The argument is defensive in tone rather than clinical

If You Include One

Keep it clinical, factual, and grounded exclusively in what the record contains. Cite the specific coverage determination and connect its criteria to specific documented findings. Avoid characterizing the contractor’s motives, arguing about the fairness of the review, or making assertions that the record does not support. In matters with enforcement exposure, counsel should review any written submission before it goes out.

Days Twenty to Forty: Assemble, Verify, and Submit

Verification Before Submission

Work through the claim inventory a final time and confirm, for each claim:

• Every requested component is present
• Every page is legible
• Patient identifiers and dates of service are correct and consistent
• Signatures are present, or attestations are included
• Pages are in the intended order and nothing was lost during scanning or copying
• Nothing unrelated to the request was inadvertently included

Submission Mechanics

Use the method the contractor specifies. Many contractors now require or prefer electronic submission through a portal, which produces an immediate confirmation and eliminates mail transit risk. Where fax or mail is used, retain the transmission confirmation or certified mail receipt.

Submit ahead of the deadline. A package that arrives on day 44 leaves no room for a transmission failure, a portal outage, or a rejected upload.

Confirm Receipt

Follow up to confirm the contractor received the complete submission. Documentation that was sent but not received is functionally documentation that was never sent, and the burden of establishing otherwise falls on the practice.

Requesting an Extension

Contractors may grant good cause extensions for documented extenuating circumstances such as a natural disaster, a business closure, or another comparable disruption.

The critical requirement: the extension request must reach the contractor before the deadline passes. A request submitted after the deadline has expired does not restore a right that has already lapsed.

Extensions are not granted because the practice is busy, because staff turnover occurred, or because the request was routed slowly internally. Where a genuine qualifying circumstance exists, submit the request in writing, describe the circumstance specifically, propose a definite alternative date, and retain proof of timely submission.

The more reliable strategy is to build the internal schedule so that an extension is never necessary.

What Happens After You Submit

Review Timeline

Contractors generally complete review within 30 to 60 days of receiving a complete submission, though timelines vary by contractor and complexity. During this period, prepayment review claims remain held.

Possible Outcomes

• No errors identified. The review closes. For TPE, this may end the process entirely rather than proceeding to the next round.
• Partial denials. Some claims are denied and referred for recoupment while others are paid or upheld.
• Full denial with overpayment determination. The findings proceed to the demand and recoupment process.
• Education offered. Under TPE, the contractor offers one-on-one education and the correction window opens.
• Escalation. Findings suggesting a pattern rather than isolated errors may prompt expanded review, extrapolation, or referral to another contractor.

Use the Interval

The period between submission and findings is working time, not waiting time. If the internal audit identified deficiencies, begin remediation now: retrain the providers involved, correct the template or workflow that produced the problem, and document what was done. Corrective action initiated before findings are issued is materially more persuasive than corrective action initiated in response to them, and it is the mechanism that prevents escalation.

The Deadlines That Follow: Demand Letters, Interest, and Recoupment

If the review produces an overpayment determination, a new and considerably less forgiving set of deadlines begins. Practices that navigate the ADR well and then miss these deadlines lose money they did not need to lose.

The Key Dates From the Demand Letter

• Day 15: Deadline to submit a rebuttal to the proposed recoupment. A rebuttal is not an appeal and does not stop recoupment, but it provides an opportunity to present information before collection begins.
• Day 30: The pivotal date. Filing a valid request for redetermination by day 30 prevents recoupment from beginning. This is the single most important deadline in the post-determination phase.
• Day 31: Interest begins accruing on the outstanding balance if the overpayment has not been paid in full. Interest is charged on the outstanding principal for each 30-day period until the debt is satisfied.
• Day 41: Recoupment begins where the overpayment has not been paid and no valid redetermination request was filed by day 30.
• Day 120: The outer deadline to file a request for redetermination. Filing between day 31 and day 120 preserves appeal rights but does not undo recoupment that has already occurred, and amounts already recouped are generally not refunded unless the appeal succeeds.

Why the Thirty-Day Date Governs Practice

The 120-day appeal deadline is the one printed most prominently, and it is the one practices tend to calendar. But recoupment starting on day 41 means that a practice using the full 120 days will have money withheld for months while the appeal proceeds. For a practice with meaningful Medicare volume, that cash flow interruption can be more damaging than the overpayment itself.

The operative deadline is 30 days. Treat 120 as the absolute outer limit, not the target.

A Note on the RAC Discussion Period

Where a RAC issued the findings, a discussion period allows the provider to submit additional documentation directly to the RAC before recoupment is set up. The discussion period is not an appeal, does not stop interest, and does not extend the redetermination deadline. Once redetermination is requested from the MAC, the discussion option closes. Sequencing these two options is a strategic decision that should be made deliberately.

The Ten Most Costly Response Errors

• Calendaring from the receipt date rather than the letter date. Costs days that cannot be recovered.
• Assuming 45 days on a UPIC request. The window is 30, and the assumption forfeits a third of the available time on the most serious audit type.
• Submitting without an internal audit. Forfeits the opportunity to identify missing documentation that exists elsewhere in the chart and to prepare for known findings.
• Altering records after receiving notice. Converts a payment dispute into a potential enforcement matter. The audit trail is visible.
• Submitting incomplete records. Missing signatures, absent orders, and unattached test results generate denials on documentation that frequently existed but was never sent.
• Sending illegible copies. Illegible is treated as absent. Poor scans and faint faxes produce denials on adequate documentation.
• Failing to retain a complete copy of the submission. Makes it impossible to establish what the contractor actually received when that becomes disputed on appeal.
• Waiting on outside records. Hospital, imaging, and laboratory records take weeks. Requests submitted late are the leading cause of missed deadlines.
• Missing the 30-day redetermination date. Triggers recoupment on day 41 and withholds cash flow for the duration of an appeal that might have been filed in time.
• Treating findings as a cost rather than a correction mandate. Unremediated findings are the mechanism by which a routine audit becomes a larger one, and by which billing errors become False Claims Act exposure.

How DoctorsManagement Supports Audit Response

DoctorsManagement has guided practices through documentation requests from every Medicare contractor as well as commercial payer special investigations units. Our involvement during the response window, before findings are issued, consistently produces better outcomes than engagement after a demand letter arrives.

Our auditors hold both the Certified Professional Coder and Certified Professional Medical Auditor credentials and receive ongoing training through NAMAS, our education division. Every auditor brings substantial experience in the specialties they review.

Our audit response services include:

• Request Analysis: Identification of the contractor, confirmation of the operative deadline, assessment of enforcement risk, and determination of what the request actually requires
• Pre-Submission Internal Audit: Independent review of each requested claim against the documentation, conducted as a contractor would conduct it, so the practice knows its exposure before submitting
• Response Package Preparation: Assembly, organization, and verification of a complete, legible, well-indexed submission, including position paper development where appropriate
• Appeal Representation: Preparation and prosecution of redetermination, reconsideration, and ALJ-level appeals, with clinical and statistical expert support
• Extrapolation Defense: Statistical analysis of sampling methodology where an overpayment estimate has been applied
• Post-Audit Remediation: Corrective action planning, provider and coder training, and workflow correction to prevent recurrence and escalation

If your practice has received a documentation request, contact DoctorsManagement at www.doctorsmanagement.com/audit-appeal-defense or call (800) 635-4040.

Frequently Asked Questions

How many days do I have to respond to a Medicare records request?

45 calendar days for MAC, RAC, and SMRC requests, and 30 calendar days for UPIC requests. The clock runs from the date printed on the letter rather than the date of receipt, so internal routing delays consume the response window. The regulatory basis is 42 CFR 405.903 for prepayment review and 42 CFR 405.929 for post-payment review.

What happens if I miss the deadline?

The claims are denied for insufficient documentation, the denials produce an overpayment, and the overpayment enters the demand and recoupment process. A missed deadline also signals a documentation problem to the contractor and can prompt an expanded review. Missing the deadline is generally worse than submitting an imperfect but timely response.

Can I get an extension?

Contractors may grant good cause extensions for documented extenuating circumstances such as a natural disaster or business closure. The request must reach the contractor before the deadline expires. Being busy or short-staffed does not generally qualify, and a request submitted after expiration does not restore a lapsed right.

Can I correct or add to the medical record before submitting?

Legitimate amendments are permitted when clearly identified as amendments, dated as of the date actually made, attributed to the individual making them, and not obscuring the original entry. What is never acceptable is creating documentation after the audit notice and presenting it as contemporaneous. EHR audit trails reveal timing, and apparent falsification converts a payment dispute into an enforcement matter.

What do I do about missing or illegible signatures?

Where documentation is otherwise complete but a signature is missing or illegible, a signature attestation statement is an accepted remedy. The attestation confirms the author’s identity and that the author provided the documented service. It does not add clinical content, which distinguishes it from substantive amendment and makes it considerably less risky.

Should I have an attorney review my response?

For UPIC and OIG matters, matters referencing investigation rather than payment review, matters involving extrapolation with significant exposure, and matters where internal review revealed a pattern of deficiencies, yes, and before the package is assembled. For routine MAC probes, TPE Round 1, and CERT requests, experienced audit defense consultants are typically sufficient.

Should I include a letter explaining the claims?

A position paper helps when medical necessity is clinically sound but not obvious from the record, when the presentation was atypical, or when supporting documentation is distributed across sources. It hurts when the documentation genuinely does not support the claim, when the explanation relies on facts absent from the record, or when the matter carries enforcement risk. Keep any position paper clinical, factual, and grounded strictly in the record.

What is the most important deadline after I receive findings?

Day 30 from the demand letter. Filing a valid redetermination request by day 30 prevents recoupment from beginning on day 41. The 120-day outer deadline preserves appeal rights but not cash flow, and amounts already recouped are generally not refunded unless the appeal succeeds. Treat 30 days as the target and 120 as the absolute limit.

Should I audit my own claims before submitting them?

Yes, and the review should be conducted by someone other than the coder or provider responsible for the original documentation. A pre-submission audit identifies documentation that exists but was not going to be included, tells you what findings to expect, and reveals whether a deficiency is isolated or systemic. That last determination may carry sixty-day overpayment obligations extending beyond the claims under review.

How can DoctorsManagement help with an audit response?

DoctorsManagement provides request analysis, pre-submission internal auditing by credentialed auditors, response package preparation, appeal representation, extrapolation defense, and post-audit remediation. Engagement during the response window produces better outcomes than engagement after findings. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• CMS Medicare Overpayments Fact Sheet (MLN006379)
• CMS Medicare Financial Management Manual, Chapter 4: Debt Collection
• Federal Register: Medicare Program, Limitation on Recoupment of Provider and Supplier Overpayments
• CMS Regulations and Guidance
• ACEP Recovery Audit Contractor (RAC) FAQ
• OIG Work Plan
• OIG Self-Disclosure Information
• DoctorsManagement Audit Appeal and Defense
• DoctorsManagement Coding and Documentation Review
• DoctorsManagement Healthcare Compliance Audit
• DoctorsManagement Total Compliance Solution

Contact Us

This article is provided for informational and educational purposes only and does not constitute legal advice. Audit procedures, deadlines, and documentation requirements are subject to change, and the appropriate response to any specific request depends on its particular facts. Practices facing a documentation request should consult qualified legal and compliance professionals. DoctorsManagement is available to provide audit response and defense consulting at any stage of the process.

The post Responding to a Medicare Records Request: The First 30 Days That Determine Your Audit Outcome appeared first on DoctorsManagement.

Introduction: The Most Forgiving Audit and the Gateway to the Least Forgiving Ones

Targeted Probe and Educate occupies an unusual position in the Medicare program integrity landscape. It is, by design, the most provider-friendly review CMS conducts. The stated purpose is education rather than recovery. The contractor offers to walk you through your errors personally. You get roughly 45 days between rounds specifically so you can fix what was found. A practice that improves exits the process and is generally left alone for at least twelve months.

It is also the doorway to the harshest tools in the program. A practice that fails three rounds is referred to CMS for further action, and the options on that menu include 100 percent prepayment review, extrapolation, and referral to a Recovery Audit Contractor. Any of those outcomes is orders of magnitude worse than the TPE that produced it.

This combination creates a specific failure mode. Because TPE presents as educational, practices tend to treat it as low stakes. Records get pulled and submitted without internal review. The education session gets delegated to whoever is available. The 45-day correction window passes without anyone changing anything, because nothing felt urgent. Then Round 2 produces the same findings as Round 1, and the practice discovers in Round 3 that it has been walking toward a cliff it never saw.

The practices that fare well are not the ones with flawless documentation. They are the ones that recognized in Round 1 that TPE is a time-limited opportunity to fix a problem on favorable terms, and used the structure the program provides.

This guide covers how selection works, what happens in each round, what the correction window is actually for, how the target error rate functions, what referral to CMS means in practice, and the connection between TPE failure and extrapolation authority that most providers never learn until it is too late.

What Targeted Probe and Educate Actually Is

TPE is a medical review program administered by Medicare Administrative Contractors. Rather than reviewing every provider who bills a particular service, MACs focus on specific providers and suppliers whose data suggests a problem with that service.

The mechanics are consistent across MACs. The contractor selects a sample of claims, generally 20 to 40 per round for a specific item or service, requests documentation, reviews it, issues a results letter, and offers individualized education addressing the errors found. The provider then has time to correct course before the next round.

The Design Intent

CMS describes TPE as designed to help providers reduce claim denials and appeals through one-on-one assistance. That framing is accurate as far as it goes. Many TPE errors genuinely are simple and correctable, with a missing physician signature being the canonical example. Education resolves those quickly and permanently.

What the framing understates is the consequence of not improving. The educational posture is real, but it is conditional. It persists only as long as the provider demonstrates progress.

Prepayment or Post-Payment

TPE samples may be drawn on either a prepayment or post-payment basis, and the notification or additional documentation request will indicate which. Most TPE reviews are conducted prepayment, meaning the claims under review are held rather than paid. For a practice with meaningful volume in the targeted service, this produces an immediate cash flow effect that continues throughout the round.

Scope Is Service-Specific

TPE targets a provider for a particular item or service, not the practice’s billing generally. A cardiology practice under TPE for a specific stress testing code is not under review for its office visits. This matters for the response, because it focuses the internal audit and remediation effort on a defined target rather than the entire billing operation.

It also means a practice can be in TPE for more than one service simultaneously, each running its own round sequence.

How Practices Get Selected for TPE

Selection is data-driven. MACs use analysis to identify two categories: providers and suppliers with high claim error rates or unusual billing practices, and items and services with high national error rates that present financial risk to Medicare. CMS has been explicit that providers whose claims are compliant with Medicare policy are not chosen, and that most providers will never experience TPE.

Provider-Level Triggers

• Claim denial rates substantially above those of specialty peers
• Billing practices that vary significantly from peer norms for the same service
• High error rates identified in prior reviews or adjudications
• Billing data suggesting questionable practices in a specific service line
• Sudden changes in volume or coding distribution for a targeted service

Service-Level Triggers

• High national error rates identified through the CERT program
• Findings and recommendations from OIG, GAO, or Recovery Audit Contractor activity
• Service categories representing significant financial risk to the Medicare program
• Historical claims trends showing deterioration in documentation compliance

What Selection Tells You

Because selection is targeted rather than random, a TPE notice carries information. Something in your data placed you outside the expected range for a specific service. The notification letter identifies the service under review and the reason for selection, and that reason is worth reading carefully rather than skimming.

If the letter indicates selection based on denial rate, the practice has a claims-processing or documentation problem that was already producing denials. If selection was based on billing variance from peers, the practice may have a coding pattern issue, or it may have a legitimate clinical explanation that its documentation has not been capturing. Those two situations call for different responses.

The Round Structure: What Happens and When

TPE runs up to three rounds. Each round follows the same sequence.

• Notice of Review. The MAC sends a letter identifying the service under review, the reason for selection, an overview of the process, and contact information.
• Additional documentation request. The contractor requests records for the sampled claims, typically 20 to 40 for the item or service under review. The standard response window is 45 calendar days from the date on the letter.
• Review. The MAC evaluates whether the documentation supports each claim as billed, including medical necessity under the applicable coverage determination. CMS guidance indicates a round should generally not extend beyond approximately six months.
• Results letter. The contractor issues written findings detailing the results of the claim reviews and classifying the error level.
• One-on-one education. Providers with moderate or major error classifications receive an offer for individualized education addressing the specific errors identified. Education may also occur during a round when easily resolved errors surface.
• Correction window. The MAC allows at least 45 days before initiating the next round, specifically so the provider has time to improve.

A provider found compliant at the end of any round exits the process and is generally not reviewed again for at least twelve months, absent significant changes in billing.

Sample Size Variations

While 20 to 40 claims is the standard range, probe samples of different sizes may be approved by CMS on a case-by-case basis. MACs are also directed to choose a claim volume such that a round does not take longer than roughly six months, and to consider closing a round with existing claims where a provider’s billing volume decreases mid-round.

Round 1: Establishing the Baseline

Round 1 establishes what the contractor believes is wrong. Everything that follows is measured against it.

Treat the ADR as an Audit Response, Not a Records Pull

The single most common Round 1 error is submitting documentation without reviewing it first. The practice receives a request for 30 claims, someone prints the encounter notes, and the package goes out. Weeks later the results letter arrives listing errors the practice could have identified itself.

Before submitting, audit each requested claim as the contractor will. Confirm that the documentation supports the service billed, that medical necessity is established under the applicable coverage determination, that signatures are present and legible, that orders and supporting results are included, and that every billed element appears somewhere in the record.

This accomplishes two things. It catches documentation that exists in the chart but was not going to be included in the package, which is a meaningful share of TPE denials. And it tells the practice what the results letter is going to say before it arrives, which converts the next 45 days from reaction into preparation.

The Compliance Standard in Round 1

Round 1 is the strictest round. A provider who achieves full compliance exits immediately. Any errors generally move the provider forward into education and a subsequent round, though the classification of those errors as minor, moderate, or major affects what happens next. Practices with a minor error classification may be treated differently from those with moderate or major findings.

What to Do With the Results Letter

Read the results letter at the claim level rather than the summary level. The summary tells you the error rate. The claim-level detail tells you the pattern, and the pattern is what you have to fix. Twelve denials caused by one provider’s incomplete medical necessity documentation is a fundamentally different problem from twelve denials spread across every provider in the practice.

The One-on-One Education Session

The education session is generally conducted by MAC provider outreach and education staff, usually by teleconference or webinar, and walks through the errors identified in the reviewed claims.

Who Should Attend

The providers whose documentation generated the errors should attend. This sounds obvious and is frequently not done. Practices routinely send the billing manager or compliance officer alone, who then attempts to relay the content secondhand to physicians who did not hear it directly and who may not accept the characterization.

The session should include the responsible providers, the coding staff who handled the claims, and whoever will own the corrective action. If a specific template or workflow produced the errors, include whoever can change it.

Questions Worth Asking

• What specific documentation element was missing on each denied claim? Get to the element, not the category. “Insufficient medical necessity documentation” is not actionable. Knowing that the record did not document a specific required finding is.
• What error rate do we need to reach to exit? CMS has indicated the target error percentage varies based on the service or item under review. Ask directly rather than assuming.
• How is improvement from round to round weighted? Movement between rounds is a factor in whether a provider advances, and understanding how the contractor evaluates it informs where to focus.
• Which coverage determination or policy governs these claims? Get the specific citation so remediation can be built against the actual standard.
• When will Round 2 begin and what will the sample cover? Establishes the working timeline for the correction window.

Document the Session

Take detailed notes and circulate them internally. If the practice later needs to demonstrate that it acted on the education, contemporaneous documentation of what was communicated and what the practice did in response is the evidence.

The 45-Day Correction Window: Your Most Valuable Asset

This is the section that determines outcomes.

The MAC allows at least 45 days between rounds explicitly so the provider has time to improve. It is the only phase of any Medicare audit where the contractor pauses, tells you what is wrong, and gives you a defined period to fix it before looking again. Nothing comparable exists in RAC, UPIC, or SMRC reviews.

Practices that use it well exit at Round 2. Practices that let it pass see Round 3.

A Working Plan for the Window

• Week 1: Diagnose the pattern. Analyze the results letter at the claim level. Determine whether errors cluster by provider, by service subtype, by documentation element, or by template. Identify the root cause rather than the symptom.
• Week 1 to 2: Fix the mechanism. If a template omitted a required element, change the template. If a workflow allowed claims to bill before documentation was complete, change the workflow. If an order was routinely not captured, build the capture step. Fixing the mechanism prevents recurrence in a way that reminding people does not.
• Week 2 to 3: Retrain the responsible providers. Target the specific documentation elements that failed, against the specific coverage determination that governs. General documentation training does not move a TPE error rate.
• Week 3 to 5: Run an internal probe. Pull 10 to 20 recent claims for the same service, billed after the remediation, and audit them against the same standard the MAC applied. This is the verification step, and it is the one practices skip.
• Week 5 to 6: Close remaining gaps and document everything. Correct anything the internal probe surfaced. Assemble a record of what was identified, what was changed, who was trained, and what the internal probe showed.

Why the Internal Probe Matters

Remediation that has not been tested is a hypothesis. A practice that retrains its providers and assumes the problem is solved has no idea whether the claims now being billed would survive review. Round 2 becomes the test, and if the remediation did not work, the practice learns that only after the round is complete and a third round has been triggered.

An internal probe of recent claims answers the question while there is still time to act on the answer. If the probe shows the error persists, the practice has weeks to address it rather than discovering the failure through the contractor.

Claims Billed During the Window

Remember that the claims sampled in Round 2 will be drawn from a period that includes the correction window and after. Remediation implemented on day 40 of a 45-day window affects very few of the claims that will be reviewed. Speed matters, and front-loading the fix into the first two weeks materially increases the share of Round 2 claims that reflect corrected practice.

Round 2: Where Improvement Matters More Than Perfection

Round 2 follows the same mechanics as Round 1: another sample of 20 to 40 claims, another documentation request, another review, another results letter, and if needed, another education session and correction window.

The Standard Shifts

Unlike Round 1, perfect compliance is not required to exit at Round 2. The provider must reach a target error rate, and CMS has indicated that the required percentage varies depending on the service or item under review. This is why asking the educator what the expectation is going into Round 2 is a practical necessity rather than a courtesy question.

Improvement from round to round is itself a significant factor. A provider who moves from a 60 percent error rate to a 20 percent error rate has demonstrated that education worked, which is what the program is designed to produce. A provider whose rate is unchanged has demonstrated the opposite.

The Diagnostic Value of Round 2 Findings

Compare the Round 2 errors against Round 1 at the element level. Three patterns are possible, and each means something different.

• The same errors persist. The remediation did not reach the point of failure. Either the wrong mechanism was fixed, the training did not reach the responsible providers, or the change was implemented too late in the window to affect the sampled claims.
• The original errors resolved but new ones appeared. Often a sign that a template or workflow change introduced a different gap. This is recoverable and typically resolves quickly once identified.
• Errors reduced but not eliminated. The remediation worked and needs to be extended. Determine whether the residual errors come from claims billed before the fix took effect, which would suggest the trajectory is better than the rate indicates.

That last point is worth raising with the contractor. If a meaningful share of Round 2 claims predate the remediation, the practice’s current compliance is better than the round’s error rate suggests, and that context is legitimately relevant to how the contractor evaluates improvement.

Round 3: The Last Exit

Round 3 uses the same process and generally the same target error rate as Round 2. What differs entirely is the consequence of failure.

At the end of Rounds 1 and 2, a provider who does not meet the standard receives more education and another opportunity. At the end of Round 3, a provider who does not meet the standard is referred to CMS for possible further action.

What Should Change in Round 3

If a practice reaches Round 3, the internal approach that produced Rounds 1 and 2 has not worked. Continuing it is not a strategy.

• Bring in external expertise. An independent auditor with no prior involvement in the claims will identify things internal review has repeatedly missed. Two failed rounds is strong evidence that the internal read of the documentation differs from the contractor’s.
• Consider prepayment internal review. Reviewing claims for the targeted service before submission, during the Round 3 period, ensures that the claims entering the sample are ones the practice has already validated.
• Escalate ownership. Round 3 warrants physician leadership attention and a named owner with authority to change clinical documentation practice, not just administrative process.
• Evaluate whether to appeal Round 2 denials. If the practice believes specific denials were wrong, the appeal outcome may be relevant. Denials overturned on appeal reflect on the accuracy of the error rate that drove escalation.
• Engage counsel if extrapolation is a realistic outcome. The exposure at the end of Round 3 may extend well beyond the claims reviewed, and the posture should reflect that.

What Happens After Three Failed Rounds

CMS is explicit that problems failing to improve after three rounds of education sessions will be referred to CMS for next steps, and that these may include 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, or other action.

Each of these deserves to be understood on its own terms.

100 Percent Prepayment Review

Every claim for the affected service is held and reviewed before payment. For a practice with significant volume in that service, this is a sustained cash flow interruption of indefinite duration, layered on top of the administrative burden of producing documentation for every single claim. Practices generally cannot operate through extended full prepayment review without external financing.

Extrapolation

The error rate found in a sample is projected across the universe of comparable claims, converting a finding measured in thousands of dollars into a demand measured in hundreds of thousands or millions. This is addressed in the section that follows and in the companion article in this series.

Referral to a Recovery Auditor

A RAC operating on contingency fee then reviews the provider’s claims, with a three-year look-back available under the baseline documentation request limit. The educational posture is gone entirely at this point.

Other Action

This category includes referral for program integrity investigation, which moves the matter from payment review into the fraud, waste, and abuse framework, with the enforcement exposure that entails.

The Extrapolation Connection Most Providers Miss

This is the most important thing in this article and it is almost never explained to providers going through TPE.

Extrapolation authority in Medicare Parts A and B is limited by statute. Section 1893(f)(3) of the Social Security Act, added by the Medicare Modernization Act, restricts the use of extrapolation to determine overpayment amounts to circumstances where the Secretary determines either that there is a sustained or high level of payment error, or that documented educational intervention has failed to correct the payment error.

The Medicare Program Integrity Manual implements this. A contractor shall use statistical sampling when it has been determined that a sustained or high level of payment error exists, and statistical sampling may be used after documented educational intervention has failed to correct the payment error.

TPE is documented educational intervention.

That is the connection. A practice that goes through three rounds of TPE without correcting its error rate has, in the regulatory framework, participated in a documented educational intervention that failed. That failure independently satisfies one of the two statutory conditions for extrapolation, regardless of whether the error rate reached the threshold that would qualify as high on its own.

Why This Reframes the Correction Window

Understood this way, the 45 days between rounds is not merely an opportunity to avoid another round of paperwork. It is the window in which a practice can prevent the government from acquiring the statutory predicate to project its error rate across three years of billing.

A practice that grasps this in Round 1 allocates resources very differently than one that treats TPE as an administrative nuisance. The cost of a serious remediation effort during the correction window is a fraction of the cost of an extrapolated overpayment demand, and the remediation is the only one of the two the practice controls.

A Related Point on Historical Noncompliance

The Program Integrity Manual also permits contractors to consider a provider’s past noncompliance for the same or similar billing issues, or a historical pattern of noncompliant billing practice. TPE findings become part of that history. A practice that resolves a TPE and later faces an unrelated review has a documented record showing the issue was identified and corrected. A practice that failed three rounds has a documented record showing the opposite.

The Four Errors That Drive Most TPE Denials

Across MACs and specialties, TPE denials concentrate in a small number of categories. Auditing your own claims against these four before Round 1 submission addresses a substantial share of typical findings.

Missing or Invalid Certifying Physician Signature

The most common and most easily corrected error in the entire program. A signature that is absent, illegible, undated, or missing credentials produces a denial on documentation that may otherwise be complete. Where a signature is illegible or was not captured, a properly executed signature attestation is an accepted remedy that adds no clinical content and therefore carries none of the risk of substantive amendment.

Documentation Does Not Support Medical Necessity

The highest-value category and the hardest to fix quickly, because it requires changing what providers write rather than adding a missing element. The failure is typically that the record documents what was done without documenting why it was clinically indicated under the governing coverage determination. Remediation requires identifying the specific criteria in the applicable policy and ensuring the documentation addresses each one.

Encounter Notes Do Not Support All Elements of Eligibility

Common where a service carries specific coverage conditions, such as frequency limits, prior treatment requirements, or clinical thresholds. The service may have been entirely appropriate while the note simply fails to establish that the eligibility conditions were met. This is frequently a template problem rather than a clinical one.

Missing or Incomplete Initial Certifications or Recertifications

Where a service requires certification or periodic recertification, absence of a complete and timely certification is a categorical denial regardless of the clinical documentation quality. This is a workflow failure and is corrected by building the certification capture into the process rather than relying on individual diligence.

A Practical Round-by-Round Action Plan

On Receipt of the Notice of Review

• Identify the specific service under review and the stated reason for selection
• Determine whether the sample is prepayment or post-payment and assess the cash flow implication
• Calendar the documentation deadline from the letter date, not the receipt date
• Assign a named owner with authority to change documentation practice, not just to collect records
• Pull the governing coverage determination for the service and distribute it to the responsible providers

Before Submitting Any Round

• Audit every requested claim against the coverage determination as the contractor will
• Confirm signatures are present, legible, dated, and credentialed, and prepare attestations where needed
• Verify orders, results, certifications, and supporting records are included, including any held by outside entities
• Organize the package claim by claim with a consistent internal structure and an index
• Retain a complete copy exactly as submitted, with proof of timely transmission

On Receipt of Each Results Letter

• Analyze findings at the claim and element level, not the summary level
• Determine whether errors cluster by provider, service subtype, documentation element, or template
• Schedule the education session with the responsible providers present
• Establish the target error rate and the contractor’s improvement expectations

During Every Correction Window

• Fix the mechanism, not just the behavior, in the first two weeks
• Retrain the specific providers on the specific elements against the specific policy
• Run an internal probe of recent post-remediation claims to verify the fix worked
• Document what was identified, what changed, who was trained, and what the probe showed

Special Case: The Low Biller Probe and Educate Program

Traditional TPE requires enough claim volume to support a 20 to 40 claim sample, which excludes lower-volume providers who might nonetheless benefit from education. CMS addressed this with the Low Biller Probe and Educate Program, a nationwide initiative that reviews fewer than 20 claims per round, for up to three rounds.

The program follows the same structure and philosophy as traditional TPE, focusing on providers and suppliers who present risk to the Medicare program based on data analysis and who could benefit from education. Education is provided consistent with the traditional program.

The practical implication for small practices is that low Medicare volume does not confer immunity from probe review. The same preparation, correction window discipline, and remediation approach applies, with the added consideration that a very small sample makes each individual claim proportionally more significant to the error rate.

Exiting TPE and What Comes After

A provider found compliant at the end of any round is removed from the TPE process for that service and generally will not be reviewed again for at least twelve months, absent significant changes in billing practice.

Do Not Let the Remediation Decay

The twelve-month reprieve is conditional on the practice’s billing remaining compliant. Practices that exit TPE and then allow the corrected practice to erode, through provider turnover, template changes, or simple drift, frequently reappear in a subsequent round.

Build the corrected documentation standard into onboarding for new providers, into the template governance process, and into periodic internal auditing. The service that drew a TPE is by definition a service where your practice was an outlier, which makes it a reasonable candidate for ongoing monitoring regardless of TPE status.

Preserve the Record

Retain documentation of the TPE, the findings, the education received, the corrective action taken, and the results. This record demonstrates that the practice identified a compliance issue and remediated it, which is materially relevant if the same or a similar issue is raised in a future review, and which bears directly on the knowledge element in any subsequent False Claims Act analysis.

How DoctorsManagement Helps Practices Exit TPE Early

DoctorsManagement has guided practices through TPE across specialties and MAC jurisdictions. Our involvement is most valuable in Round 1 and during the first correction window, because that is where the outcome is actually determined.

Our auditors hold both the Certified Professional Coder and Certified Professional Medical Auditor credentials and receive ongoing training through NAMAS, our education division. When we review your claims, we review them the way the contractor will.

Our TPE support services include:

• Pre-Submission Claim Audit: Independent review of every requested claim against the governing coverage determination, identifying missing documentation that exists in the chart and forecasting the contractor’s findings before submission
• Response Package Preparation: Assembly of a complete, organized, indexed submission, including signature attestations and supporting records from outside entities
• Results Letter Analysis: Root-cause analysis of findings at the element level, distinguishing provider-specific, template-driven, and workflow-driven error patterns
• Correction Window Remediation: Template and workflow correction, targeted provider training against the specific policy criteria, and internal probe auditing to verify the remediation before the next round begins
• Provider and Staff Training: Documentation education delivered by credentialed auditors using the practice’s own denied claims as the teaching material
• Escalation Defense: Where TPE has progressed to Round 3 or referral, appeal representation, extrapolation defense with statistical and economic expertise, and coordination with counsel

If your practice has received a TPE notice, contact DoctorsManagement at www.doctorsmanagement.com/audit-appeal-defense or call (800) 635-4040. The correction window is a fixed asset that depletes daily.

Frequently Asked Questions

What is Targeted Probe and Educate?

TPE is a Medicare Administrative Contractor medical review program that combines small claim samples with one-on-one education. MACs use data analysis to select providers with high claim error rates or unusual billing practices, and items or services with high national error rates. Each round reviews 20 to 40 claims for a specific service, followed by a results letter, individualized education, and at least 45 days to improve before the next round.

How many claims are reviewed in each TPE round?

Typically 20 to 40 claims per provider per item or service, though CMS may approve different sample sizes case by case. The Low Biller Probe and Educate Program reviews fewer than 20 claims per round for lower-volume providers. MACs are directed to select a volume that keeps a round to approximately six months.

How long do I have between TPE rounds?

At least 45 days, allowed specifically so the provider has time to improve. This window is the most valuable asset in the process. Remediation implemented in the first two weeks affects more of the claims that will be sampled in the next round than remediation implemented late in the window.

What error rate do I need to reach to exit TPE?

Round 1 generally requires full compliance to exit immediately. For Rounds 2 and 3, CMS has indicated the required target error percentage varies based on the service or item under review, and improvement from round to round is a significant factor. Ask the MAC educator directly what the expectation is rather than assuming, since the answer is service-specific.

What happens if I fail all three rounds of TPE?

The MAC refers the provider to CMS for possible further action, which may include 100 percent prepayment review, extrapolation, referral to a Recovery Auditor, or other action including program integrity referral. Each of these is substantially more damaging than the TPE itself.

Can TPE lead to extrapolation?

Yes, and this is the connection most providers miss. Section 1893(f)(3) of the Social Security Act limits Part A and Part B extrapolation to situations where there is a sustained or high level of payment error, or where documented educational intervention has failed to correct the payment error. TPE is documented educational intervention. Failing three rounds independently satisfies one of the two statutory conditions for extrapolation.

Is TPE prepayment or post-payment?

Samples may be drawn on either basis, and the notification or documentation request will specify which. Most TPE reviews are prepayment, meaning the claims under review are held rather than paid, which creates an immediate cash flow effect for practices with meaningful volume in the targeted service.

Who should attend the one-on-one education session?

The providers whose documentation generated the errors, the coding staff who handled the claims, and whoever will own the corrective action, including anyone with authority to change the affected template or workflow. Sending an administrator alone to relay the content secondhand is a common and costly shortcut.

How long am I left alone after exiting TPE?

A provider found compliant is generally not reviewed again for that service for at least twelve months, absent significant changes in billing practice. That reprieve depends on the corrected practice holding, so the remediation should be built into onboarding, template governance, and ongoing internal auditing rather than treated as a one-time fix.

How can DoctorsManagement help with a TPE audit?

DoctorsManagement provides pre-submission claim auditing, response package preparation, results letter root-cause analysis, correction window remediation with internal probe verification, targeted provider training, and escalation defense including extrapolation challenge. Contact us at www.doctorsmanagement.com/contact-us or call (800) 635-4040.

External Resources and References

• CMS Targeted Probe and Educate (TPE) Program Page
• CMS Targeted Probe and Educate Questions and Answers
• CMS TPE Process Flow Chart
• Medicare Program Integrity Manual, Chapter 8
• CMS Manual Transmittal on Statistical Sampling (R11797PI)
• CMS Medicare Overpayments Fact Sheet (MLN006379)
• CMS Regulations and Guidance
• OIG Work Plan
• DoctorsManagement Audit Appeal and Defense
• DoctorsManagement Coding and Documentation Review
• DoctorsManagement Compliance Training for Physicians and Staff
• DoctorsManagement Total Compliance Solution

Contact Us

This article is provided for informational and educational purposes only and does not constitute legal advice. TPE procedures, sample sizes, target error rates, and escalation criteria are subject to change and vary by MAC and by the service under review. Practices in TPE should consult qualified compliance professionals regarding their specific circumstances. DoctorsManagement is available to provide TPE response and remediation support at any round.

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‘Given their age’ is an excuse we’ve all heard many times – Sharif Islam debunks some of the ageism that patients face when seeking dental treatment.

Almost every time I’m in the gym, members inform me that ‘someone my age’ shouldn’t be able to, or even try to, move from an L-sit to a handstand on suspended rings, hold a front lever, or helicopter kick in an elevated split. And while I’m the first to admit that at my age merely getting out of a chair is now a Hollywood stunt that requires careful planning and copious warming up before making the obligatory middle-aged grunts, I seem to defy their expectations by performing all the aforementioned actions anyway. Well, so far, at least… (When I leave the hospital tomorrow I’ll see if that’s still true.)

But when it comes to our patients, many of us have read a familiar rationale in the notes to explain why a cavity wasn’t filled or a broken tooth wasn’t restored. Because, apparently, being a certain age negates the obligation for real dentistry to be undertaken, and excuses the supervised neglect and therapeutic nihilism that is unfortunately too often bestowed upon our more senior patients.

‘Given their age’ is a convenient pass to get out of the jail that would otherwise confine us to working on an ageing mouth with a multitude of problems – a mouth belonging to someone we perceive as having far fewer days ahead of them than behind them.

But the judgement that they haven’t much time left in the realm of the living is no more ours to make than the excuse to not correctly treat them because of it. Are we genuinely treating the individual sitting in front of us, or are we treating our assumptions about their age?

What is behind the ageism?

It is true that some of our elderly patients are not entirely lucid, aware, or tolerant of treatment. Trying to restore that cavity in the distal half of an upper third molar belonging to a patient who cannot recline and has a perpetual tremor is a tall ask of any of us. And in any situation, we can only do our best or refer on to someone who can, even if those community or domiciliary services are stretched or curtailed.

It’s the use of their age as the excuse that is so invidious. One day, if you’re lucky, you will also be that age, as will hopefully your other family members and your children. Would it be acceptable for someone to judge you or them less worthy of appropriate care because of advancing years?

Ageism in dentistry is rarely malicious but often unconscious. Treatment discussions may be addressed to family members instead of the patient, despite the patient having full decision-making capacity. Either the practitioner or the family member may assume that an older patient would not want implants because they’re too old, or dismiss cosmetic concerns because appearance is somehow considered less important later in life. And these assumptions are rarely challenged because they masquerade as kindness.

The case against ageism in dentistry

Every competent adult deserves the opportunity to understand their options and make informed choices. That principle doesn’t diminish with age. Nor is oral disease an inevitable consequence of ageing. Dental caries, periodontal disease, tooth wear and oral cancer remain diseases regardless of age. When we normalise deterioration simply because someone has reached a certain age, we inadvertently lower the standard of care.

Elderly dental patients may present with a complex and particular plethora of health predicaments. Polypharmacy, xerostomia, diabetes, cardiovascular disease, cognitive impairment and reduced manual dexterity all influence oral and dental health. These factors demand more thoughtful treatment planning, not less.

Typically, such patients are the least likely to feel entitled, make a fuss or escalate a complaint. In contrast, it is my humble experience that elderly patients are usually the most grateful to us for a modicum of care, even if it’s a just a few minutes of listening to them. A human connection that is as much appreciated as the clinical treatment.

Patient preference and clinical excellence

Ageism won’t cause all dentists to hold back on treatment. For many, the opposite is true. The elderly demographic is often seen as a naively trusting cash cow presenting ample opportunity for the practitioner to exploit their buffet of dental complications. Implants or dentures to replace missing teeth, lots of class V wear and abfraction cavities to fill in with composites, and a few root canals to cover with crowns. Naturally, all of it will help prolong their life and quality of it.

Ultimately, the patient’s own values have to be aligned with good clinical dentistry. For some it will be enough to be without pain just to get through their day. Others will prefer a full mouth rehabilitation. Thus, comprehensive assessment becomes essential. Functional ability, cognitive capacity, social support, nutritional status, medical history and patient priorities will influence treatment planning.

‘Age is only a number; health is a necessity’

People are living longer, healthier and more active lives than ever before in human history. Many individuals in their 80s, 90s and even beyond now retain much of their natural dentition and have expectations of oral health that would have been unimaginable a generation ago. They are not only living longer. They expect to live better. Such that studying gerodontology may be an inescapable necessity on the dental syllabus rather than a specialist afterthought.

Our elderly citizens in general are not simply a date of birth but merit much more patience and consideration than our current culture seems to award them. They have invariably put in their time, made their contribution to society, and belong to a generation that rarely complained but endured privations and hardship that many of us would find challenging to bear.

Such a fact of their existence should surely marshal us into doing our absolute utmost to ensure they have nothing less than stable dental health with a comfortable, pain-free mouth. They deserve the same dignity and commitment to excellence that we would expect for ourselves and deliver without hesitation to our younger patients.

And, as was stated to me recently by a sage septuagenarian gym member after finishing his inverted sit-ups: age is only a number; health is a necessity.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends. 

Jennifer Gallagher explains how mediation can help dental practice owners resolve business disputes, succession challenges and partnership disagreements confidentially.

Businesses are all about relationships between the people running them. When there are differences in opinion about direction, succession planning or other difficult conversations needed, it can be tricky working out how best to handle things. Worst case scenario the business relationship is breaking down and the personal relationships are making resolving things much harder for everyone involved. Mediation has been used successfully by separating couples for many years, and can be a useful option in these situations.

Examples of cases where mediation can help are many and varied. It may be a partnership where the behaviour of one partner impacts staff and other partners. It may be someone retiring from the business where it is proving difficult to agree satisfactory terms. Or, it could involve a dispute with a current or former associate or an employee.

How does mediation work?

Mediation is a voluntary, non-court dispute resolution (NCDR) process. A mediator is a neutral person and their job is to facilitate discussion that allows settlement of the dispute. The mediator does not act as a legal advisor or judge. The parties in a mediation can have their own solicitors take part in the process in an advisory capacity. Discussions can take place at mediation on a without prejudice basis and possibilities can be fully explored as the whole process is confidential. By contrast court cases are heard in public and can bring reputational damage for businesses as a consequence.

The mediator will meet the parties individually to find out what is in dispute and what is important to each party that they achieve at mediation. Then the mediator will arrange joint sessions.

The process can be tailored to fit the needs of the parties – it may involve booking a full or half day with lawyers present too and working to get a settlement in that time or there can be shorter more spread out sessions. Most mediators are flexible and can also offer meeting times outside normal business hours – unlike civil courts where there is little choice on date or time with no guarantee the case will actually proceed on the allocated date. Mediations can be scheduled quickly and can fit in with what the clients need in terms of logistics.

What are the benefits?

Using conventional means can be costly and drawn out. There may be serious disruption to the smooth running of the business. Mediation can allow parties an opportunity to have practical, without prejudice discussions. Everything at the mediation is private and particularly where each party involves their own solicitor for advice during the mediation, settlement terms can be agreed far more easily than having the dispute sorted out by a court.

The model for mediation is constantly evolving. Many mediators now have options like involving arbitrators to come in to decide legal points that then allow the mediation to carry on to a conclusion. Often fee packages are offered giving certainty in costs. Outcomes in mediated cases tend to be far better for the parties themselves too – the parties arrive at settlement after discussion rather than settlement being imposed on them from outside by a court.

Alongside our specialist knowledge of dental practices, Thorntons have a team who are experienced in resolving disputes through mediation, and we would be happy to provide advice to anyone in need of assistance. Contact Thorntons on 03330 430350.

This article is sponsored by Thorntons.

Niall Kent explains how an unexpected discovery inspired him to develop a novel tooth sensitivity gel which provides relief on the go.

Niall Kent, an oral and maxillofacial surgeon, stumbled on the extraordinary solution for tooth sensitivity when he was asked by his brother, who worked at the Royal Academy of Art, to create sculptures using aerogels.

He explained: ‘Aerograft incorporates calcium and phosphate into an aerogel, precipitating a mineral called hydroxyapatite. These particles mix with the water in saliva and fill the dentinal tubules. Sensitivity is fundamentally caused by open tubules allowing access to the nerves inside the tooth.’

How is the sensitivity gel better than existing products?

Ozen’s on-the-go gel uses this technology to provide relief from sensitivity in less than 30 minutes. This is considerably faster than the previous gold-standard in sensitivity treatment, which would generally take around 22 hours to take effect.

The innovation was partly inspired by Niall’s observation that colleagues were recommending patients apply normal anti-sensitivity toothpaste to affected areas and leave it there. He pointed out that toothpaste contains abrasive ingredients and has a very strong taste in high concentration – making it less than ideal for prolonged contact with the mouth.

The new sensitivity gel eliminates the unnecessary ingredients found in toothpaste and has twice the concentration of actives. Niall considers it a completely new solution with no previous equivalent.

Dental therapist Benjamin Tighe said: ‘I can really see a place for Ozen alongside tooth whitening treatments. Its fast-acting formula is particularly appealing, especially when compared with conventional desensitising toothpastes, making it a valuable option for patients seeking rapid relief from sensitivity.’

The impact of tooth sensitivity on patients and dental professionals

Niall feels that the impact of dental sensitivity is often overlooked. While one third of the population reports issues with sensitivity, it is estimated that 50% of sufferers do not recognise their symptoms.

Commenting on the impact that tooth sensitivity can have on patients’ lives, Niall said: ‘Severe sensitivity affects what people eat, so they might avoid cold, hot or sugary food and drinks because they cause pain. It has quite a big impact on their life and what they can enjoy, and it also affects their behaviour when seeking dental care. Often, patients won’t go to hygiene visits because it causes them pain.’

Addressing sensitivity can therefore benefit dental professionals as they are less likely to lose patients and experience failures to attend.

Niall continued: ‘As it stands, there isn’t really a good solution that dental professionals can utilise before treatments such as tooth whitening that might cause sensitivity.’

He advises first identifying potential triggers for a patient’s sensitivity, then recommending Ozen’s sensitive formula toothpaste, following up with the topical gel if needed.

This advice can be incorporated into protocols surrounding sensitivity-inducing treatments such as whitening and hygiene visits.

Sweta Surana Bhandari, a dental therapist, agreed that the gel could be useful in practice. She said: ‘I think we definitely need a gel which could help with sensitivity during scaling and help to ease discomfort for both clinician and the patient. I don’t know if this specific gel will be effective but we need a better solution than extended application of sensitivity toothpaste.’

Positive early feedback for the sensitivity gel

Niall has already received positive feedback from clinicians using the gel in practice, for example before scaling.

He said: ‘A number of dental hygienists and therapists have found that patients are much more comfortable during the procedures when using the gel.’

It has also seen great success in a 1,200-person user trial. More than 89% of users saw a reduction in sensitivity after just one use, while 100% saw improvement within a month. A further 77% said they were more able to enjoy hot and cold foods and drinks.

The next step for Niall and the Ozen team will be developing more products that address patients’ pain and discomfort, whether in practice or in their daily lives. In general, Niall is interested in ‘other problems in dentistry where current solutions aren’t good enough’.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

Ahead of her keynote at the GBT Summit London 2026, leading women’s health expert Dr Nighat Arif joins Celso Da Costa to discuss why hormonal health should be part of every oral health conversation.

Celso Da Costa (CD): Public awareness of women’s health, particularly menopause, has grown significantly in recent years. Why do you think oral health has remained relatively absent from that conversation until now?

The conversation is changing because patients are demanding more complete, better joined-up care, and the evidence is catching up. We’re finally starting to treat oral health as part of whole-body midlife health, not an unrelated side note.

CD: What are some of the biggest misconceptions about the relationship between hormonal health and oral health, both among patients and healthcare professionals?

NA: A big misconception is that hormones only affect reproductive symptoms, not the mouth. In reality, fluctuations in oestrogen and progesterone can change gum sensitivity, saliva flow and inflammation, so bleeding gums, dry mouth or a burning sensation can be hormonal, not just ‘bad brushing’.

Another myth is that oral health is separate from whole-body health. That’s not true: pregnancy, breastfeeding, menopause and other hormonal shifts can influence the oral microbiome, periodontal disease risk and even tooth loss risk, especially where gum disease is already present.

Among patients, a common belief is that if your dentist hasn’t mentioned hormones, they can’t be relevant. Among health professionals, the bigger gap is under-recognition, with symptoms often treated in isolation rather than being linked to midlife hormonal change.

There’s also a dangerous oversimplification: ‘it’s just ageing’. Age matters, but hormones can be a distinct driver, especially when symptoms appear despite good oral hygiene. That’s why this conversation matters now; it helps women get the right support sooner, not after damage has built up.

CD: Which oral changes associated with menopause, as well as other hormonal transitions, do you believe are most overlooked in dental practice, and what should dental professionals be looking out for?

NA: The most overlooked changes are dry mouth, burning mouth, gum inflammation, altered taste and subtle bone loss around the teeth. These often get written off as stress, ageing, or ‘just sensitivity’, when they may actually reflect menopause or other hormonal shifts.

Dental professionals should be looking for women with new or worsening bleeding gums, recurrent mouth discomfort, increased decay risk and signs of periodontal breakdown despite good hygiene.

It’s also worth asking about life stage, perimenopause, menopause, postpartum, breastfeeding and even conditions such as polyendocrine metabolic ovarian syndrome (PMOS), endometriosis, adenomyosis and uterine fibroids, because hormones can change oral tissues long before a patient makes the connection.

The key is not to treat the mouth in isolation. If the pattern doesn’t fit the usual oral picture, hormones should be part of the conversation.

CD: If every dentist, dental hygienist and dental therapist made one change to the way they approached conversations around hormonal health, what would you hope that change would be?

NA: I’d hope they’d start asking, not assuming. One simple, routine question about hormonal life stage, symptoms and recent changes could open the door to earlier recognition, better tailoring of care and far fewer women being told their symptoms are ‘just normal’ or ‘just ageing’.

That small shift would make oral health feel connected to whole-body health, which, for hormonal changes, it absolutely is.

CD: What do you think is the biggest conversation around hormones and oral health that dentistry has yet to have, and what are you most looking forward to discussing at the GBT Summit 2026?

NA: The biggest conversation dentistry and medical colleagues still need to have is this: hormones are not a side note; they are a clinical context.

I’m most looking forward to seeing oral health discussed as part of women’s whole-body health, where dry mouth, bleeding gums and tissue changes are seen as early warning signs, not isolated complaints across the woman’s whole lifespan.

That shift could change how we screen, educate and care, especially at moments like menopause, pregnancy and postpartum, as well as lifelong gynaecological conditions such as PMOS, endometriosis, adenomyosis and uterine fibroids.

Now is the time to connect the dots between hormones and the mouth, so we can stop normalising symptoms that deserve proper attention.

Continue the conversation at the GBT Summit London 2026

The GBT Summit London 2026 brings together an outstanding speaker line-up, including Dr Nighat Arif on hormones and oral health, Ben Tighe and Claire Berry on menopause in practice, Dr Payvand Menhadji on implant longevity, Dr Devan Raindi on MINST and biofilm management, Dr Simon Chard and Dr Christian Leonhart on AI in dentistry, and Celso Da Costa on the business of prevention.

Taking place on Friday 2 October at 30 Euston Square, London, the event offers a full day of practical, evidence-based education. Book your place now.

This article is sponsored by EMS.

That challenge is accelerating as health care data increases by more than 36% annually and medical misinformation rises alongside it. Surveys show that 86% of physicians believe medical misinformation has increased over five-years, and global studies find 70% of people believe at least one of six divisive health claims about foods, vaccines and medicines.

For physicians, this infodemic poses a pressing challenge: How to deliver high-quality, evidence-based care when the integrity of medical science itself is constantly under threat?

The following is an abridged version of an article written by Stephen Parodi, MD (link to full article at the end) exploring how clinicians can navigate conflicting guidance, preserve patient trust, and approach misinformation with courage and conviction. It’s the result of a recent fireside chat he moderated with guests Jason M. Goldman, MD, MACP, immediate past president of the American College of Physicians, and Letitia Bridges, MD, MBA, chief quality officer with The Permanente Federation.

Translating evidence into trust

Patients now encounter health information from search engines, social media, influencers, and AI-generated answers — often mixing credible facts with misinformation. That uncertainty can open up important conversations, but it can also erode trust and undermine the patient-physician relationship. Clinicians need to understand how these tools are created, what data they use, and how to evaluate them.

That makes trusted evidence more important than ever. When guidance appears inconsistent, health systems, medical societies, universities, and research organizations must help clinicians and patients navigate information with transparency and rigor. Kaiser Permanente and groups such as the Common Health Coalition are strengthening resources to support evidence-based clinical guidance.

But evidence alone is not enough. Physicians must translate science into trust by communicating clearly, acknowledging uncertainty, and using everyday language that addresses patients’ concerns. “Science is an iterative process,” Dr. Bridges said. Trust is rooted in relationships as much as research, and empathy is essential to helping patients make informed decisions.

Let curiosity and courage guide the conversation

Approaching misinformation requires curiosity and courage. If a patient brings a deeply held belief shaped by misinformation, dismissal should not be the first response. A simple invitation — “Tell me more” — can keep dialogue open. As Dr. Goldman observed, clinicians can often make the greatest difference with people who are unsure, want more information, and are open to new evidence.

This work takes persistence. Physicians may repeat difficult conversations many times a day, yet each one matters because patients carry what they hear into their families, workplaces, and communities. In this information age, the physician’s influence extends well beyond the exam room.

Speak up where health information is shaped

Not every physician needs to host a podcast or post on social media. But more trusted clinical voices in public spaces would help. Medical excellence increasingly requires the willingness to speak up, listen before correcting, acknowledge uncertainty without surrendering confidence, and show up as a trusted voice in the community.

Perhaps this is the new civic duty of physicians, as Dr. Bridges noted: “We need to be ambassadors not only of science, but actually of well-being and health and togetherness,” wherever health information is shaped and shared.

To read the entire article, click here.

The post Restoring trust in medicine, one conversation at a time appeared first on Permanente Medicine.

In this episode of the Permanente Medicine Podcast, host Chris Grant sits down with John Yang, MD, president and medical director of the Hawaii Permanente Medical Group (HPMG), to explore the unique culture and community-oriented approach to health care delivery in Hawaii.

As the leader of the state’s largest physician-led multi-specialty practice, Dr. Yang explores the geographic, demographic, and public health challenges of delivering care across the Hawaiian islands. The conversation digs into how HPMG has leveraged health care innovations to overcome access barriers across the islands.

Listeners will learn how deep community ties help build the trust needed to effectively support communities during natural disasters, like the devastating Lahaina wildfires. The episode highlights how cultivating deep community relationships and cultural understanding drives better patient outcomes both in the exam room and beyond.

Dr. Yang also discusses HPMG’s proactive efforts to build a sustainable physician workforce, including growing their own talent through local training programs and providing robust support for clinician wellbeing.

Watch the full episode on YouTube:



Connect with Chris Grant by following him on X at @cmgrant or LinkedIn.

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Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

John Yang, MD: The culture here is very much relationships. It’s about getting together. It’s important to invest in these relationships before problems arise. I think as we try to get groups together when there’s a crisis, if we don’t have that foundational relationship, then the trust is not there and we’re not able to work through things as effectively.

Chris Grant: Welcome to the Permanente Medicine Podcast. I’m your host, Chris Grant, the chief operating officer of The Permanente Federation at Kaiser Permanente. Today, I’m joined by a dear friend, Dr. John Yang, president and medical director of the Hawaii Permanente Medical Group. He leads the state’s largest physician-led multi-specialty practice with more than 700 physicians and clinicians providing care for 270,000 members across the state. From its geography and landscape, diverse population, and health needs, Hawaii is a unique health care environment. Today, we’re excited to explore the challenges and opportunities of practicing medicine in Hawaii at the community level and across the state. I’m really excited about this conversation because when we were together recently in Washington, D.C., meeting with congressional leaders to talk about Permanente Medicine and value-based care, I was so impressed with how you, Dr. Yang, shared our Hawaii story. And I know the policymakers were too. So now it’s time to turn to our audience and help them learn about your amazing work. Welcome and mahalo.

JY: Thank you. Thanks for having me. Excited to be here today.

CG: All right, let’s dive in. Before we get too deep into the conversation, John, tell us a bit about your journey into medicine and what ultimately drew you into medical leadership.

JY: So I was born and raised in Southern California, left California for about 8 years for medical school, for my family medicine training. Did a one-year fellowship in faculty development and medical informatics, and then ultimately returned to Southern California. I joined SCPMG in Orange County in 2001. I also always had an interest in technology from building my own computers to doing that medical informatics fellowship. And around this time, there was lots of discussion around the promise and the future of electronic health records. I feel like in some ways I got into leadership by accident. I always had a desire to make things better, improve processes, workflows. I would tend to ask a lot of questions and really be willing to try new things. And as I look back now, and I think a couple of experiences really helped shape the foundation of my leadership journey in addition to the many mentors that we all have that shape us personally.

Taking on a role as the physician-in-charge in a large multi-specialty clinic in Orange County, that was the foundation of helping me understand clinical operations, and it was also the foundation of the value and importance of a physician-led medical group. I was leading primary care in Orange County, but had this unique opportunity to come to Hawaii in 2020 in the midst of COVID. Very challenging time, lots of unknowns. But as I reflect back, super proud of our being a part of the state of Hawaii’s outstanding COVID response. Hawaii managed that pandemic highly effectively. We had some really unique things that we’re super proud of. We achieved the lowest age-adjusted COVID-19 death rate in the US, the lowest rate of excess mortality, all in the middle of the ocean in a place that didn’t always have all of the resources that other places have. Thinking back on why the state was so successful, I think a lot of combination of things, but things that mattered, rapid geographic containment, swift policy interventions, high vaccine compliance, and something that we didn’t see everywhere else was a deep community cooperation.

I’ll leave you with one fact that I think is pretty impressive that KP Hawaii delivered over a million doses of COVID vaccine. I’m pretty remarkable when you consider the population of Hawaii is about 1.4 million.

The importance of trust and cultural understanding in practicing medicine

CG: That is amazing. It’s delivering vaccines to 70, 80% of the entire state. It all makes sense to me of why you’re so successful in Hawaii because Hawaii is so relationally oriented and understanding people and building trust is really what it’s all about. What a heroic situation to dive into, to relocate to Hawaii, to one of the most isolated places of geographic concentration on the globe, and to be very responsible for the COVID response, not just to the Kaiser Permanente members and patients, but to the entire population. Speaking of culture and diversity, Hawaii is a diverse place that’s very distinct from other regions of the country. Can you talk a bit about the importance of connection and trust in practicing medicine in a place like Hawaii?

JY: For sure. It doesn’t take long for people to be connected by just a couple of degrees of separation. And what I learned very quickly coming to Hawaii that for so many that health care isn’t just a profession, it really is very personal. We’re caring for neighbors and classmates and teachers and family members. I know that happens everywhere to a degree, but it really happens here in Hawaii. Some statistics that are interesting, Hawaii’s ranked 40th in terms of state population, but I think because of the island state and also because the island of Hawaii is broken up into multiple islands, making those communities even smaller. Folks feel a ton of accountability to each other. Going back to the trust and the relationships are essential to so much of what we do, but they’re especially essential to effective care delivery here on the islands. I know moving from California that I know it takes time for folks from outside of Hawaii to earn and build that trust.

And as a medical group, we spend a great deal of effort onboarding, acculturating our new physicians and clinicians who join us from outside of the state to ensure that they’re successful here. Cultural humility really matters here. Understanding local values, family structures, so many multi-generational households, understanding those traditions aren’t just important. They actually improve outcomes. Our doctors, our physicians, our clinicians are often leaders in the community. They’re not just physicians and clinicians here. Many of our physicians will hold important, valuable, and multiple roles in community organizations.

CG: Every time I have worked in Hawaii and visited members of your team, I understand the connection that they have with the community. And in fact, there’s often stories about school groups, religious groups, community groups, and philanthropic that they’re deeply involved in and that they care about. And it’s far beyond, here’s my patient panel, and it’s all about here is my community that I serve, and that I’m so deeply committed to serving. And every time I leave Hawaii, I leave with a lot of learning. On that note, is there a lesson in community connection that you’ve discovered that might be helpful? We have an audience of physicians and leaders from across the country that might be helpful for them in other parts of the country.

JY: I think some of these things work everywhere, but I think in Hawaii it’s maybe even more valuable and important. The culture here is very much relationships. It’s about getting together. It’s important to invest in these relationships before problems arise. I think as we try to get groups together when there’s a crisis, if we don’t have that foundational relationship, then the trust is not there and we’re not able to work through things as effectively. So we’ve seen the value of that investment upfront sometimes when you don’t even think you need that investment or that relationship just yet.

As an organization, KP Hawaii, and especially within the medical group of HPMG, we spend a lot of energy and effort to bring people together and bring people together in person. We bring them together proactively to create these stronger connections. Even though it’s a small place because we’re separated by water, not all of our team gets to interact with each other on a regular basis.

So we make a point of investing in that as an important foundation for our trust and our accountability to each other. I mean, all of this is super critical in a Permanente model where really exceptional care requires interdisciplinary skills, it requires coordination across multiple specialties, inpatient, outpatient. And I will say listening, understanding what’s happening, following through on your commitments, not just hearing what people are saying, but actually listening and following through on what you commit to are often more important than necessarily having the perfect solution.

Strategies for taking on physician shortages

CG: And I hope our listeners are listening and just that conscientiousness of those steps and those tools is really quite important. Fostering a supportive environment for physicians is a key part of maintaining the workforce that delivers quality care to the communities we serve like Hawaii. And I don’t think I’ve been on a flight or met somebody that was visiting Hawaii that happened to be a physician where I don’t get to know them and actually try to recruit them when I like them into HPMG because I really do believe it’s one of the best places in the entire country to practice. Could you talk about some of the ways the Hawaii Permanente Medical Group works to attract and retain physicians?

JY: It may be a little bit of an unknown fact, but Hawaii faces the worst physician workforce shortage in the country. Sounds very obvious, but visiting and traveling here is very different from living and working here. One thing you’ll find is that our people tend to wear many hats. So people who are comfortable wearing several hats do well. Geography creates a lot of its own unique challenges from limited local training pipelines, distance from professional as well as family networks for our recruits, high cost of living, and all of those things are challenging in Hawaii as a whole, but even more challenging as we get out to our neighbor islands. And some of the work that we’ve done over the last 5 to 10 years that is bringing some long-term success is really a strategy to grow our own where it makes sense. Seeking recruits with some connection to Hawaii tends to make a difference.

We’ve done a lot supporting local students, career shadowing opportunities. We’ve got a key partnership with the medical school here on the island, the University of Hawaii, John A. Burns School of Medicine. A little bit more than 10 years ago, we created an internal medicine residency program that’s been very successful for us. And then just looking for pathways for physicians to return home, either through mentorship, other relationships has also been very vital and critical for us. As I think a little bit about retention, which is the other half of the recruitment, trying to understand why physicians stay. As I’ve witnessed as part of this medical group, it’s really the culture, the purpose, a strong sense of collegiality and connection outside of the usual stuff around compensation, but certainly not the only factor. As a group, we spend a lot of time and investment on physician wellbeing. We have a program that we call SELF CARE that’s very diverse and supportive of our physicians and clinicians.

We spend a lot of energy trying to reduce the administrative burden on them and let them be doctors and physicians and clinicians. And ultimately, I really believe the best recruitment strategy is creating an environment where physicians want to build a life and not just take a job.

Health care innovations overcoming Hawaii’s barriers to access

CG: And for all of our physicians or soon-to-be residency graduates, you heard it here first that there’s a high degree of support and collegiality, wellness programs, and a deep commitment to culture and community that exists in HPMG. And I know it’s way beyond words because I’ve witnessed it, John, under your leadership and with the leadership of the medical group, how deeply committed the group is to each other and to really creating a family. I’m going to move us forward here to talk a bit about access to care through innovation. As we all know, access to preventative care like screening and early detection is vital to improving outcomes and ultimately keeping care affordable. Can you discuss some of the specific barriers to access that are present in local communities and underserved populations? And related to that, what initiatives or innovative digital health tools are you excited about using to overcome some of those barriers?

JY: In many ways, I will say our geography forces us to innovate. We can’t be everywhere. And so I will say innovation’s not optional for us in a way. It’s really how we can ensure patients get access to care regardless of which island they call home. I think being part of a value-based organization allows us to do this in ways that make sense for patients and for our organization and not always have to be driven by how we’re reimbursed. So I think if anybody is set to be able to do this well and do it right, it is an organization like Kaiser Permanente. Things that are pretty normal now, I think we were maybe more on the forefront of pre-COVID, but obviously virtual care, video visits, telehealth, remote patient monitoring, and really any digital tools that help bridge distance. For us, it’s not just innovating for technology’s sake.

It really is with the lens of improving access to people that might be very far away from the expertise that’s needed. Some of the examples I think are pretty commonplace now are virtual specialty consultations. It’s very challenging to have every specialty available physically on all of our islands. Our rural communities are tough to get to, so we do a lot with remote care, remote patient monitoring, anything that allows us to reduce travel for our patients, which can be a barrier, or for our physicians to get out to the different islands, that can impact access as well. And then I think another area that we’ve tried to be really innovative with in a different way is just culturally responsive approaches to care. One of our really proud foundations is our newest West Oahu medical office, and it’s the only Kaiser Permanente facility in the program with a taro garden.
This is a garden that our people are out regularly harvesting and then providing that resource to patients in the communities.
Building care delivery connections before disasters hit

CG: I’ve had the privilege of visiting that garden and working that field alongside you, and it’s an amazing connection to the community and a demonstration of HPMG and Kaiser Permanente’s linkage to the local community. Hawaii has faced serious natural disasters in recent years from fires and flooding to annual threats of hurricanes. I think we have it tough in California. And then I look at Hawaii and what you have dealt with and led through. From a system-wide operations perspective, could you talk about the role Kaiser Permanente played in responding to these many challenges?

JY: Sure, Chris. And just for the record, it’s not a competition for any one of us wanting to be number one in natural disasters, but they are a very real part of life here. And like you mentioned it, hurricanes, flooding, volcanic activity, wildfires, tsunami threats. These aren’t things that might happen. These are all things that have happened and they’ve all happened relatively recently. I think one that most people remember from the very recent past was the Lahaina wildfires. And I will say this level of community trust is especially important during these crises and disasters and public health challenges. And during these Lahaina wildfires, I will say a lot of pride with our ability to respond what I think was very effectively, but I think we were able to do that because of the investment upfront. Our Maui teams had a strong relational culture. They wanted to be on the front lines of care that we were providing immediately after the fires.

Our Oahu teams backed them up for the other clinical work. And I will say this was also a demonstration of amazing support from our Kaiser Permanente enterprise in so many ways. Disaster planning’s more than just about us. This is coordination across multiple health care delivery systems. We had to work with the government, community organization, emergency responders. And I know firsthand if we didn’t have that relationship and trust built beforehand, and I think a lot of that we built during the COVID pandemic, I don’t think we would’ve been as successful in our response. But because we had those relationships, we had that trust, they knew that we were helping for the right reasons, that allowed people to let their guard down and let us in to help them in a way that if we had just come in during the crisis and the wildfires, they may have been more cautious or suspicious of why we were helping.

CG: It comes back to your earlier comments about relationships and building trust in the community long before there’s issues or challenges so that you can work through and really be effective. And I’m always in awe at the positivity and respect in the community in Hawaii that Kaiser Permanente holds. People love the organization, and they also often have a family member that they tell me about that’s a physical therapist or a nurse or a doctor, and they’re very proud of that. Staying in line with responding to natural disasters, it’s not just the community that’s affected, but it’s also the workforce. And I wanted to get a bit of your insight, John, on how you go about preparing physicians, all of our clinicians for disasters on both a personal and a professional level.

JY: It is a very real thing, this idea of workforce resilience and how important it is. As you mentioned, our caregivers are often disaster victims themselves. The health system isn’t just responding to the community, but we’re literally in and a part of those communities. And we had physicians, clinicians, we had staff lose homes in the Lahaina fires, and we mobilized to support them. KP also did something very innovative on Maui, I think people should be aware of, helping to sponsor health care workforce housing on the island. And been an exciting moment, one of our physicians who lost his home in the Lahaina Fires was actually one of the first to be able to live in one of those homes.

The future of health care in Hawaii

CG: Digging deep into that crystal ball, Dr. Yang, what excites you the most about the future of care in general, but also its impact on Hawaii?

JY: After years of seeing both the positive and the challenging impacts of the electronic health record, I’m really excited that technology that enhances rather than replaces, especially that primary care physician-patient relationship. In our organization, we’ve seen how various forms of AI have been fairly quickly implemented and seeing some really positive movement in reducing the administrative burden on our physicians and clinicians with charting, hearing from our physicians that they feel like their attention and focus and time are turned back towards patient care. Lots of technology in other innovations in our specialty, surgical specialties, our surgeons and other specialists are able to do more now with less impact on our patient. A few things that we’ve got in place in Hawaii in the last couple of years, but we’ve really had some amazing advancements and tools that allow us to biopsy parts of the lungs that traditionally were either difficult or impossible to reach.

We’re seeing more complex vascular procedures with advances in fluoroscopy technology. Robotic surgeries just become a part of the way we do business. Our robotic surgeons continue to discover new ways to use our robots at the Moanalua Medical Center, doing procedures that nobody else is able to do here in Hawaii. Another part that I think we have to keep paying attention to besides the technology, but the future workforce, the next generation of physicians, they’re going through one of these sea changes in terms of what people expect out of their physicians. So continuing to invest and develop the next generation of physicians, really investing in creating sustainable practice environments. Super important, especially here in Hawaii where we already have a huge physician shortage. And if people are retiring early because the work is not sustainable, we continue to lose people and worsen that physician shortage problem. Ultimately, I would say what excites me the most is this possibility of giving physicians more time to do what drew them into medicine in the first place, ultimately caring for patients.

CG: That’s beautiful. And I think that is the promise of technology in many ways. And some of the early adoption of electronic medical records and advanced technology probably complicated physicians’ engagement with patients. It might’ve helped from a technical perspective, but the actual kind of face-to-face environment. And now I think the evolution of technology, as you’ve pointed out, whether it’s ubiquitous listening and documentation or advanced diagnostic data analytics capabilities, it just gives more time for that physician to be the mentor, to be the coach, the motivator to that patient that they care so deeply about. John, I can’t tell you how glad I am that when you were called upon in the depths of a pandemic to move yourself and your family to a small island out in the Pacific, that you raised your hand and said yes, because not only are 270,000 patients and members benefiting, but all of the Hawaiian islands.

Your leadership and the team that exists in Hawaii is nothing short of phenomenal. And your informatics background and your understanding of technology allow even one of the most remote and sometimes rural parts of health care to be one of the earliest adopters of some of the most advanced technology. And it’s a combination of creating the right culture and having the right insight. So I thank you for your leadership and for saying yes because it changed the lives of really so many people.

JY: I just want to thank the many people that have supported both myself on a leadership journey as well as the affiliation between Southern California and the Hawaii regions. Our Southern California leadership team has been incredible, very supportive there when we need them, but allowing us to do what is right for the population here in Hawaii. And I have to thank the Hawaii team. It really has been my honor and privilege to be able to serve as the president and medical director for the last five going on 6 years. They really welcomed me with open arms and outsider from California who they occasionally make fun of and force to pronounce difficult Hawaiian words, but I also know that they have embraced me and I couldn’t have done this job without them.

CG: It’s so important that we learn about the diverse stories and health care challenges of the people and practices we serve. There’s always valuable lessons of how value-based care across all of our regions works, and this conversation was no exception. I want to thank you for sharing your insights and for the work you and your team are doing to care for the communities across Hawaii. And I want to thank our listeners to the Permanente Medicine Podcast for tuning in. If you enjoyed this episode, be sure to subscribe, share with your colleagues, and stay tuned for more conversations with physicians and other great leaders shaping the future of health care. Until next time, I’m Chris Grant. Thanks for listening.

The opinions expressed on this podcast are those of the speakers and are not necessarily the views of Kaiser Permanente, the Permanente Medical Groups, or the Permanente Federation.

The post Podcast: Rooting care in Hawaii’s communities appeared first on Permanente Medicine.

Around 100 aspiring dentists, dental students, early-career clinicians, specialists and educators gathered at the Royal College of Surgeons in July for the first Budding Black Dentists conference, a sold-out event designed to make specialist careers more visible and accessible to Black dental professionals.

The conference comes at a time when Black, Black British, Caribbean and African dentists account for just 2.1% of the UK dental register, according to the General Dental Council’s latest registration statistics. While representation has improved slightly in recent years, it remains low, particularly within dental academia, where Black clinical academics continue to be significantly underrepresented.

For Budding Black Dentists CEO and founder Simisola Fynn-Famodun, the aim was to make specialist careers feel tangible.

Creating pathways into specialist dentistry

The conference programme offered seven hours of CPD. It combined specialist panel discussions with hands-on workshops in implant dentistry, suturing and intravenous cannulation, allowing delegates to experience skills associated with specialist practice rather than simply hearing about them.

‘We had clinical as well as educational exposures,’ says Fynn-Famodun.

The programme itself was shaped by the community. Before confirming speakers and sessions, Budding Black Dentists asked prospective attendees what they wanted from the day. Alongside specialist careers, delegates requested discussions on financial planning, technology and innovation, and wellbeing.

‘We were literally just listening,’ she says. ‘That’s what I mean by intentional.’

Even the venue was carefully chosen.

‘To specialise, you actually have to do specialist exams at the Royal College of Surgeons,’ Fynn-Famodun says. ‘So we said, yeah, we’re going to see if we can get our conference at that venue just to have that link.’

The practical approach appeared to resonate.

Fynn-Famodun said some delegates told her that they ‘didn’t know that speciality existed,’ she says. ‘This is my first time… getting stuck in with suturing, or… I didn’t know dentists do cannulation. It was just a lot of exposure.’

For dentist and Budding Black Dentists’ social media manager Dara, the conference, which was supported by Bupa Dental Care, addressed a gap that many young professionals experience.

‘I think there were a lot of early career dentists as well, just like myself, who haven’t actually had the exposure to specialties for a prolonged period of time,’ she says.

Why representation matters

The conference is the latest chapter in a journey that began with conversations Fynn-Famodun had while studying dentistry at the University of Plymouth and working part-time at Asda.

When she told people she was studying dentistry, many responded by saying they had once wanted to enter the profession but never believed it was achievable.

‘I remember they’ll ask me what I’m doing, and I say dentistry, and they’ll be like, “Oh, I wanted to do that.”‘

The reasons soon became familiar.

‘There was a lot of people saying I wanted to do that, but there were so many barriers… “I didn’t know how to get into the profession… I didn’t think I was smart enough to get in.”‘

Her own experience had been different. During work experience, she met a Black practice owner, giving her a sense that dentistry was an attainable career.

‘I never saw it as something that was unattainable to me. But I realised that was a barrier that other people experienced.’

Those conversations led to the creation of Budding Black Dentists in 2020, initially providing free mock interviews, mentoring and outreach to support aspiring dental students.

Representation, however, extends beyond who enters the profession.

Fynn-Famodun recalls attending a two-hour lecture on sepsis before another Black student went home to research how the condition presents in darker skin because it had not been covered in teaching.

‘She said she’d love to know how to identify sepsis in her own family. Unfortunately… we weren’t shown how to identify that in a darker-skinned individual.’

The experience became a defining moment for the organisation, highlighting the importance of improving diversity within the dental curriculum as well as the workforce.

Evidence of impact

Although the conference was the organisation’s first, its impact was measured in the people returning through the doors.

Former attendees of Budding Black Dentists’ mock interview workshops approached the team to say they were now studying dentistry.

‘There were some dental students who were coming up to us saying, “Hey, we’ve actually partook in your mock interview workshop a few years back, and now we’re in dental school.”‘

One has since joined the charity as a volunteer.

Dara experienced something similar. Students recognised videos she had posted while still at dental school and explained how seeing someone who looked like them had encouraged them to pursue the profession.

‘Just hearing those stories, it just made me realise that what the work that we’re doing is actually having an impact,’ she says.

Budding Black Dentists has no plans to grow simply for the sake of it. Future conferences, Fynn-Famodun says, will continue to be shaped by what the community says it needs.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

When most people think about antibiotic stewardship, they consider preventing antibiotic resistance. This goal remains critically important because antibiotic resistance is a persistent threat to human health. In addition, there are other benefits that we don’t often talk about: reducing greenhouse gas emissions and other pollutants, decreasing cost, and increasing quality of life for patients. Every unnecessary antibiotic prescription carries an environmental footprint. Antibiotics require energy-intensive manufacturing, packaging, transportation, storage, and disposal. When antibiotics are prescribed unnecessarily, these resources are consumed without improving health. Antibiotic production contributes to greenhouse gas emissions and unused medications become pharmaceutical waste. For antibiotics, healthcare professionals can help protect both patient health and planetary health by selecting the right drug, dose, and duration, and embracing diagnostic stewardship. Diagnostic stewardship means choosing tests wisely. Such stewardship has been associated with decreased unnecessary use of antimicrobials. For example, doctors who order fewer chest x-rays to diagnose childhood bronchiolitis also tend to order fewer unnecessary antibiotics. Every laboratory test requires plastics, reagents, electricity, transportation, and waste disposal. Microbiology testing requires energy intensive autoclaving or incineration before samples go to a landfill. Refraining from ordering an unnecessary test saves money, saves patients time, and diminishes trash. What about cost? The U.S. health system is one of the most expensive in the world per capita. Many of our patients experience financial stress from medical expenses. In a poll done in 2025, nearly half of adults said that they have trouble affording their healthcare (see figure). Decreasing unnecessary testing and treatment can help these patients. Every unnecessary antibiotic prescription carries an environmental footprint. Antibiotics require energy-intensive manufacturing, packaging, transportation, storage, and disposal. When antibiotics are prescribed unnecessarily, these resources are consumed without improving health. Antibiotic production contributes to greenhouse gas emissions and unused medications become pharmaceutical waste. For antibiotics, healthcare professionals can help protect both patient health and planetary health by selecting the right drug, dose, and duration, and embracing diagnostic stewardship. Finally, we think about patients’ quality of life. We know that antibiotics are associated with diarrhea and other side effects. In children, we know that broader drugs like amoxicillin/clavulanate is associated with worse quality of life indicators as reported by parents. We know that antibiotics force many patients to go to the emergency department each year for real or perceived allergy or for other side effects. And we know about the risk for Clostridium difficile disease after antibiotic use. Every health professional that I know entered medicine because they wanted to help people. Let’s help our patients and the public by thinking carefully before prescribing antibiotics. References: Emily S Spivak , Jessica Tobin , Adam L Hersh , Alexis P Lee. Greenhouse gas emissions due to unnecessary antibiotic prescriptions, Antimicrob Steward Healthc Epidemiol  2024 Sep 4;4(1):e114.  doi: 10.1017/ash.2024.354/ Antibiotics and adverse quality of life: https://jamanetwork.com/journals/jama/fullarticle/2666503#google_vignette Image: KFF Health Tracking Poll (May 5-25, 2025). About the Author: Dr. Preeti Jaggi is Professor of Pediatrics and Infectious Diseases at Emory University School of Medicine, and Medical Director of the Antimicrobial Stewardship Program at Children’s Healthcare of Atlanta, Georgia. Her email is preeti.jaggi@emory.edu

The post Antibiotic Stewardship: An Untapped Resilience Solution first appeared on My Green Doctor.

A dentist has been erased after a patient seeking ‘Hollywood smile’ treatment was left with failing crowns and bridges, poorly restored teeth, gingivitis caused by ill-fitting restorations, retained roots, a fractured root, periapical pathology and bone loss.

The General Dental Council’s (GDC) Professional Conduct Committee found that the registrant failed to provide an adequate standard of care between August 2020 and August 2023, including failures in pre-treatment investigations, treatment planning, radiographic practice, discussing risks and diagnosing the need for further treatment.

It also found that the dentist provided a poor standard of treatment and care, failed to obtain informed consent, and failed to cooperate with GDC investigations by not providing sufficient evidence of indemnity and employment information.

The determination said the patient’s evidence was that they did not know they would receive full crowns rather than overlays and were not informed about the risks of the treatment.

The committee said actual and ongoing serious harm had been caused to the patient.

‘Lack of insight’

The registrant did not attend or have representation at the hearing. The committee noted that they had requested to be erased on multiple occasions, including a few days before the hearing.

The committee heard that the dentist was a director and registered manager of the practice. It found that the dentist knowingly permitted an unregistered and erased former dentist to practise dentistry at the practice and that clinical notes and treatment plans were signed in the dentist’s name.

The GDC’s expert witness said the dentist’s conduct fell ‘far below the standard expected’ of a registered dentist.

The committee said there was no evidence of insight, remorse or remediation. It also found a high risk of repetition and said the conduct suggested an attitudinal problem.

In its sanction decision, the committee said conditions would not protect the public or satisfy the public interest because the registrant was unlikely to comply with them.

It also said suspension would not be sufficient because there was no evidence that any period of suspension would change the dentist’s behaviour.

The committee said erasure was the only appropriate and proportionate sanction. It also imposed an immediate suspension order to cover the appeal period.

The dentist’s existing interim suspension orders were revoked because the substantive erasure and immediate suspension order had been imposed.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends. 

Growing a medical practice is a good problem to have, but growth inevitably creates difficult decisions. I work with several smaller practices coming out of the start-up phase who are looking to grow.

One of the most common questions I hear from physician owners is:

“We’re booked out for weeks. Should our next hire be another physician or a nurse practitioner/physician assistant?”

There’s no universal answer.

While many practice owners immediately compare salaries, compensation is only one piece of the equation. The right hiring decision depends on your patient population, payer mix, provider productivity, supervision requirements, recruitment market, and long-term strategic goals.

Hiring the wrong provider can create years of unnecessary overhead and missed opportunities. Hiring the right one can dramatically increase patient access, improve physician satisfaction, and accelerate practice growth.

Before making a six- or seven-figure investment in your next provider, here’s what every practice should consider.

Start by Identifying the Capacity Problem

Practices often assume they need another physician simply because schedules are full.

Instead, ask a more important question:

What type of work is creating the bottleneck?

If your physicians spend much of their day handling routine follow-ups, chronic disease management, medication checks, post-operative visits, or other lower-acuity encounters, a nurse practitioner (NP) or physician assistant (PA) may effectively absorb much of that workload.

On the other hand, if demand is driven by complex medical decision-making, procedures, surgeries, or subspecialty referrals, another physician may provide a far greater return.

The objective isn’t simply to add another provider.

It’s to add the provider whose skills best match the services your patients actually need.

When a Mid-Level Makes the Most Sense

For many independent practices, hiring an NP or PA is the fastest and most cost-effective way to increase patient access.

Potential advantages include:

• Lower compensation and recruitment costs
• Faster hiring in many geographic markets
• Increased appointment availability
• Improved continuity of care
• Reduced physician workload and burnout
• Better delegation of routine clinical services

When implemented effectively, mid-level providers don’t replace physicians, they multiply physician productivity.

By shifting appropriate visits to a qualified NP or PA, physicians can dedicate more time to complex cases, procedures, surgeries, and other higher-value services.

This team-based approach often improves both patient access and financial performance.

When Hiring Another Physician Is the Better Investment

Although physicians require a substantially larger financial commitment, they also bring capabilities that cannot be delegated.

A physician may be the better choice when your practice needs:

• Additional procedural capacity
• Expanded surgical volume
• More complex patient management
• Stronger referral relationships
• New service lines or specialties
• Greater autonomy for future growth

For practices planning expansion into new markets or preparing for long-term growth, another physician may create opportunities that extend well beyond additional patient visits.

In many cases, a physician hire strengthens the overall value of the practice while expanding its clinical reputation within the community.

Look Beyond Compensation

One of the biggest mistakes practices make is comparing salaries instead of profitability.

A provider earning twice as much is not necessarily twice as expensive if they generate significantly greater collections.

Instead of asking:

“Which provider costs less?”

Ask:

• How many patient encounters can this provider realistically support?
• What collections should we expect?
• How long will it take to build a full schedule?
• What additional staffing will be necessary?
• What will the provider contribute after compensation and overhead?

These questions reveal the true return on investment.

We’ve seen physicians struggle to meet productivity expectations despite high compensation packages. We’ve also seen experienced mid-level providers become some of the most profitable clinicians within a practice.

The numbers, not assumptions, should drive the decision.

Don’t Ignore the Recruiting Market

The best hiring plan on paper is meaningless if you can’t recruit the provider.

Across much of the country, physician recruitment has become increasingly competitive. Many searches remain open for six to twelve months, while signing bonuses and relocation packages continue to rise.

Meanwhile, experienced NPs and PAs are often available sooner and at a lower recruitment cost.

Delaying growth because an ideal physician isn’t available may ultimately cost far more in lost revenue than hiring a qualified mid-level who can begin seeing patients much sooner.

Recruitment realities should always be part of your hiring strategy.

The Best Answer May Be Both

For many successful independent practices, the decision isn’t physician or mid-level.

It’s physician and mid-level.

A collaborative care model allows physicians to focus on complex patient care, procedures, surgeries, and practice growth while mid-level providers manage routine visits, follow-up care, preventive services, and chronic disease management.

When roles are clearly defined, this approach often leads to:

• Better patient access
• Higher provider satisfaction
• Increased physician productivity
• Stronger financial performance
• More scalable long-term growth

Rather than replacing physicians, mid-level providers become force multipliers that allow physicians to practice at the top of their license.

Make the Decision with Data, Not Assumptions

Every practice is different.

The right hiring decision depends on your specialty, patient demand, reimbursement environment, staffing model, recruitment market, and strategic objectives.

Before committing to a provider, practices should develop financial projections, evaluate expected productivity, analyze staffing needs, and understand how the new hire will impact both revenue and operating expenses.

A thoughtful analysis today can prevent costly hiring mistakes tomorrow.

At DoctorsManagement, we help physician practices evaluate provider expansion opportunities through financial modeling, productivity analysis, compensation planning, and strategic consulting. Our goal is simple: ensure your next provider investment supports sustainable, profitable growth.

Ready to Add a Provider?

Whether you’re considering another physician, an NP, or a PA, making the right decision starts with understanding the numbers. Contact DoctorsManagement for a provider for expansion analysis and guidance before making your next hiring decision.

Contact Us

The post Physician vs. Mid-Level: Which Provider Should Your Growing Practice Hire Next? appeared first on DoctorsManagement.

• New review strengthens the case for beetroot juice
• The single-leg glute bridge test: a useful screening tool or not?
• Is the Achilles ankle training device a game-changer?

New review strengthens the case for beetroot juice

A recent systematic review and meta-analysis pooled data from numerous studies investigating the effects of beetroot juice supplementation on both aerobic and anaerobic exercise performance. Beetroot juice is naturally rich in dietary nitrate. Once ingested, nitrate is converted to nitrite by bacteria in the mouth before being further converted into nitric oxide within the body.

Nitric oxide is thought to enhance athletic performance through several mechanisms, including dilating blood vessels to increase blood flow, improving oxygen delivery to working muscles, and enabling muscles to perform the same amount of work while using less oxygen.

The review found that beetroot juice supplementation resulted in significant improvements in several performance measures, including VO₂max, peak power output and sprint performance. However, it is important to note that these improvements were generally small to moderate rather than dramatic.

Notably, the most commonly used supplementation protocol across the studies involved consuming approximately 6–8 mmol of nitrate around two to three hours before exercise. Coincidentally, many commercially available concentrated beetroot juice shots provide a similar dose of nitrate.

Overall, this systematic review and meta-analysis strengthens the evidence that beetroot juice supplementation can provide meaningful benefits for both aerobic and anaerobic exercise performance. However, athletes and coaches should view it as a strategy to gain small, worthwhile improvements rather than expecting substantial performance gains.

The single-leg glute bridge test: a useful screening tool or not?

An online article has recently suggested that the single-leg glute bridge is an effective test for predicting injury risk in runners. According to the article, runners who can hold a single-leg glute bridge for 20 seconds or more have a 49–64% lower risk of sustaining a running-related overuse injury than those who can only hold the position for 9 seconds or less.

Interestingly, the article is based on a study published last year that included an impressive sample of 867 marathon runners. However, there are several important caveats to consider. Firstly, this was an observational study, not a randomised controlled trial. While the researchers found that runners who performed better on the single-leg glute bridge test were less likely to sustain a running-related overuse injury, the study cannot establish that improving glute bridge performance will directly reduce injury risk.

Secondly, the strength testing was self-reported. Participants completed the tests themselves at home, meaning the researchers did not directly supervise or measure performance. Consequently, differences in technique, timing and reporting accuracy may have influenced the results. Furthermore, injuries were also self-reported rather than confirmed by healthcare professionals, meaning some injuries may have been misclassified or not reported at all.

Therefore, despite the large sample size and promising findings, the single-leg glute bridge should currently be viewed as a potential screening tool, or one component of a broader injury risk assessment, rather than definitive evidence that improving performance on the test will reduce injury risk.

If you would like to learn more about testing and screening, our courses Movement Screening and Performance Assessments are well worth checking out.

Is the Achilles ankle training device a game-changer?

Sports science and technology guru Alec Grawe recently showcased a new ankle training device called the “Achilles” in a YouTube video. This innovative device is quickly gaining popularity thanks to its unique 360-degree resistance system, designed to target every movement of the ankle and said to enhance stability and mobility.

In the video, Grawe discusses how athletes are turning to this device for ankle injury prevention, recovery, and strength building. He emphasises that ankle training is often overlooked and underappreciated. However, he cautions that using the “Achilles” doesn’t guarantee you’ll never roll your ankle again.

While the concept behind the “Achilles” is based on sound evidence, the device itself hasn’t yet undergone rigorous testing to prove its effectiveness. So, while it may be a game-changer, the benefits can also be achieved through balance training, traditional ankle–strengthening exercises, such as calf raises and plyometrics like pogo hops, single-leg hops, and landing drills.

If you would like more information on ankle training, check out our course Ankle Sprain Rehabilitation.

From us this week:

>> New course: Menstruation in Sport
>> New podcast: Why Energy Management Is the Next Big Performance Tool
>> New infographic: Salivary Immunoglobulin
>> New article: Hydrotherapy

Access to a growing library of sports science courses

SFS Academy is an all-access membership to premium sports science education.

With SFS Academy, you’ll learn from some of the best coaches around the world as they teach you how to apply the latest research and practice with your athletes.

The post The Latest On Beetroot Juice appeared first on Science for Sport.

In this episode of the BizTalk Podcast, OSMS Director of Marketing & Business Development, Darin Schumacher, and orthopedic surgeon, Dr. Joseph McCormick, explore topics shaping healthcare today, including innovation in orthopedic care, advancements in treatment, healthy aging, and the important role movement plays in maintaining long-term wellness. Their conversation offers valuable insights into how healthcare providers can continue to improve patient outcomes while keeping people at the center of care.

Joseph McCormick, MD, Orthopedic Surgeon

A Marshfield, WI native, Dr. McCormick earned his medical degree from the Medical College of Wisconsin in Milwaukee. After medical school, Dr. McCormick served his residency in orthopedic surgery at the University of Colorado Health Sciences in Denver. Dr. McCormick is a board-certified general orthopedic surgeon.

Patients of all ages benefit from Dr. McCormick’s orthopedic expertise as he sees and treats a wide variety of orthopedic conditions. His services are comprehensive, with an emphasis in joint replacement, robotic assisted total knee arthroplasty, sports-related injuries, upper extremity and trauma. He has prevailed over the most complicated cases and knowing he is helping people and making a difference in their lives is his greatest reward.

Darin Schumacher, Director of Marketing & Business Development

Darin has over 25 years of experience working in the marketing and communications industry. He provides a well-rounded perspective to marketing as he has worked with both creative agencies and independent practices. A UW-Green Bay graduate, Darin currently is the Director of Marketing & Business Development for Orthopedic & Sports Medicine Specialists (OSMS) where he is responsible for all marketing efforts and works with businesses to help lower their healthcare spend by utilizing OSMS for specialty care. He also believes in giving back serving on boards or volunteering for organizations like UW-Green Bay Alumni Advisory Board, Friends of Pals, Youth & Families, Miracle League of Green Bay, and Donate Life Wisconsin.

The post BizTalk with Score: Valuable Insights into What is Shaping Today’s Orthopedic Healthcare through Evolving Innovation and Advancements appeared first on Orthopedic Sports Medicine Specialists (OSMS).

The post VIDEO: Testosterone Alone is Not a Replacement for Lifestyle Changes in Older Men at Risk of Type 2 Diabetes appeared first on Endocrine News.

The post Fall Meetings Offer World-Class Learning for Both Clinicians and Researchers appeared first on Endocrine News.

What if a dental appointment could tell patients more about their heart, their genes and their future health than their last GP visit?

That prospect was discussed at Bupa’s Dental Health is… Live roundtable, a curated conversation on how dentistry is changing and what that could mean for the wider healthcare system.

Chaired by Mark Allan, general manager for Bupa Dental Care, the discussion ranged across genomics, saliva diagnostics, artificial intelligence (AI), personalised prevention and the growing role employers could play in oral health. 

The roundtable made a compelling case for dentistry to move beyond a reactive repair service towards a frontline setting for prevention that connects oral health with wider health and long-term risk.

Beyond the dental check-up

Professor Iain Chapple MBE, professor of periodontology and consultant in restorative dentistry at the University of Birmingham and Birmingham Community Health NHS Foundation Trust, opened by drawing a distinction between personalised care and personalised medicine.

Personalised care, he explained, starts with the individual’s biology, behaviour and circumstances. Personalised medicine goes further, using genetics, lifestyle data and behavioural insight to identify targeted treatment before disease develops.

Dentistry, he argued, is better positioned to deliver this than most of medicine realises.

‘I used to hate the term checkup, because for me it trivialises it,’ Professor Chapple said. ‘But it’s proactive monitoring, isn’t it? You need to see people when they’re well, do the risk assessments, work out what might develop, and then put the prevention programmes in place.’

That reframe matters. Dental teams already see patients when they are well. They have regular, repeated contact. They have the opportunity to identify risk, support behaviour change and catch early signals, as long as the tools and frameworks exist to act on them.

Starting with the patient

Ela Sarwar, a dental hygienist currently studying towards a master’s in neuropsychology to deepen her understanding of human behaviour, argued that personalisation begins before the clinical examination even starts.

‘Before they open their mouth, I like to discover who they are,’ she said. ‘Personalisation starts right at the beginning, with great communication, with building trust, with building understanding.’

Behaviour change, she added, happens when advice connects with something that genuinely resonates with the patient.

That principle is particularly key as dentistry becomes more data-led. Genomics, biomarkers and AI can make risk more visible, but the value of those tools depends on whether patients understand what the information means and feel able to act on it.

Genomics in the waiting room

But fear not, the tools to help are closer than many practitioners may realise. Dr Rebecca Rohrer, clinical innovation and genomics director for Bupa Global, India and UK, described how genomic insight is already beginning to shape preventive care at scale.

Bupa has carried out whole genome sequencing on 16,000 individuals across Spain, Polandand the UK. The findings were striking: 99% of participants were identified as having variants associated with altered medication effectiveness or increased risk of side effects, while 77% had elevated polygenic risk, an estimate of an individual’s likelihood of developing common conditions such as cancer, diabetes and cardiovascular based on multiple genetic factors.

The practical application has already launched. Bupa’s medication check, currently using a saliva sample and moving to a cheek swab, shows how individuals are likely to respond to commonly prescribed and over-the-counter medications. It also supports preventive pathways for conditions including breast cancer, diabetes and cardiovascular disease.

‘You are now going to have a cohort of customers who are going to understand how they are likely to respond to medicine that they are on now or will be on in the future, presenting to dental practices,’ Rebecca said.

For dental teams, this has immediate implications around analgesia, antibiotics and risk management as more patients arrive informed about their own genomic profile. The crossover with diabetes and cardiovascular disease, conditions already linked to periodontal health, makes that overlap especially significant.

The mouth as diagnostic environment

The potential of saliva as a diagnostic medium threaded through much of the discussion. Professor Chapple described the mouth as a rich source of immune markers and local inflammatory signals, measurable through crevicular fluid and saliva. Panels of biomarkers have already been identified that could help distinguish health from gingivitis, periodontitis and treatment response.

The challenge is translating that complexity into usable clinical insight. Step forward AI.

Professor Chapple said: ‘It’s going to help us remove the background noise and say, well, actually, this is a signature in saliva for somebody that’s got severe gum disease or is going to develop it.’

When risk becomes visible and measurable, prevention becomes easier to explain, monitor and engage with. Dental care starts to become part of a continuous health picture.

Prevention beyond the practice

That communication challenge also extends into the workplace. Mark Allan noted that a high proportion of Bupa’s private medical insurance (around 85%) and dental cover (98%) is supported through the workplace. Dental benefits, he suggested, are well placed to support conversations about prevention that employees might not otherwise have.

Matt Sayers, benefits director at CME Group, was quick to add: ‘Employees love benefits they can use.’

Realism alongside ambition

But while optimism and opportunity were at the forefront, perspective and realism were never far away. Andrew Bower, head of the dental professional business at Philips, offered the sharpest reality check of the afternoon.

‘This is the cutting edge,’ he said, ‘but the reality is 70% of people today around the globe are still using a manual toothbrush. We’re a long way from biosensing and linking systemic health.’

The point was grounding rather than defeatist. The future of dentistry may involve genomic risk profiles, saliva biomarkers and AI-assisted diagnostics. Its success will also depend on health literacy, access and the daily habits that most patients still need support with.

The panel also recognised the risk that innovation could widen inequalities if access does not keep pace, with David Westgarth, associate editor of the BDJ Portfolio, warning that dentistry needed a ‘level playing field’.

The roundtable suggested dentistry already has a larger healthcare role than many patients, employers or policymakers recognise. The opportunity, and the challenge, is to make that role visible, practical and valuable.

Professor Chapple, reusing a slogan from the World Health Organization’s Bangkok Convention, offered the neatest summary: ‘No health without oral health. Simple and brilliant in its simplicity.’

Follow Dentistry on Instagram to keep up with all the latest dental news and trends.

Online casino sites have become one of the most vibrant corners of the digital home entertainment globe. Their appeal lies in the blend of excitement, convenience and constant technology. Gamers no longer need to visit physical venues to experience real-money video gaming. Rather, they can open a mobile application or web browser and access hundreds of video games within mins. This comfort has actually created a brand-new generation of gamers who value adaptability and rapid access over standard online casino routines.

The development of secure payment techniques and reliable systems has also strengthened trust. Accredited operators comply with stringent regulations, while modern encryption technologies protect every transaction. Therefore, players really feel safer depositing and taking out funds on-line than ever.

The Selection of Games Available Today

One of the strongest benefits of on-line gambling enterprises is the sheer deepness of their video game libraries. Digital platforms supply everything from timeless pokies and modern-day video clip slots to table video games like blackjack, roulette and baccarat. Online dealership areas add an additional layer of realistic look by streaming human croupiers directly to the gamer’& rsquo; s display. These workshops integrate real online casino ambience with the comfort of playing at home.

The consistent release of new titles keeps the experience fresh. Game service providers frequently introduce upgraded mechanics, enhanced graphics and appealing bonus offer rounds. With numerous choices readily available, players can switch over in between motifs and gameplay styles without feeling limited.

Rewards and Promotions That Forming Player Experience

On-line gambling establishments typically stand out via their marketing systems. Rewards can enhance very early sessions, expand gameplay time and supply a chance to discover new games. Although every offer has specific problems, the structure of bonuses plays a significant function in bring in new gamers. Operators create unique incentives for different sorts of users, making certain novices and seasoned gamers alike can locate something that matches their style.

Promotions also construct lasting interaction. Routine incentives, special occasions and exclusive https://testtest-test.com/perevirka/ campaigns assist preserve rate of interest even after the initial deposit. This recurring value is just one of the reasons why many gamers stay loyal to details gambling enterprise brand names.

The Value of Mobile-First Platforms

Mobile video gaming has changed the entire online casino site market. Most players currently access their preferred video games through smartphones instead of desktops. This shift has actually encouraged operators to optimise every attribute for smaller screens, making mobile experiences smoother, quicker and extra user-friendly.

Touch-based user interfaces allow all-natural interaction with games, while light-weight application variations use instantaneous access without jeopardizing on high quality. Mobile-friendly style also makes certain players can take pleasure in quick sessions during breaks or commutes. Because of this, mobile casino sites have actually come to be the key entrance to on-line gaming for several customers worldwide.

Safety and security, Licensing and Responsible Video Gaming

Depend on is the structure of on-line casino success. Reliable operators obtain permits from recognised authorities and comply with stringent regulative regulations. These permits verify that games make use of audited arbitrary number generators which payouts adhere to clear regulations. Financial systems additionally play a important role, as encrypted transactions and modern safety devices secure sensitive information.

At the same time, responsible gaming devices assist make sure that players remain in control. Functions such as deposit limits, cooldowns and self-exclusion choices produce a safer and a lot more encouraging atmosphere. The industry remains to progress with new policies made to protect gamers from risky behaviours.

The Future of Online Gambling Establishment Enjoyment

The future of on the internet gaming points towards also better technology. Virtual reality experiences, boosted live-dealer communications and ultra-fast settlement systems are ending up being extra common. Game programmers explore motion picture graphics and advanced technicians that make electronic play extra immersive.

As innovation continues to advance, on the internet casino sites will likely deliver a lot more customised experiences. Tailored suggestions, adaptive rewards and interactive features will certainly shape the next stage of electronic gaming. The market reveals no signs of decreasing, and gamers can anticipate an progressively abundant and appealing atmosphere in the years ahead.

Join David Nelkin on 11 August at 7pm as he discusses the two growth levers most practices forget: existing patients and the community on your doorstep.

Most practices pour their marketing budget into chasing strangers through Google and Meta, while ignoring the two cheapest, most reliable sources of growth they already have – the patients in their database and the community on their doorstep.

This webinar walks through the full system for both: how to reactivate dormant patients and turn existing ones into referrers, and how to build a structured local marketing layer across partnerships, healthcare networks, schools, corporate, events and media. The practices doing this consistently outgrow the ones spending more on ads.

Learning outcomes

• Identify the five highest-value growth opportunities sitting inside their existing patient base and apply a practical system for each: reactivation, treatment follow-up, family marketing, internal recommendations, and structured referrals
• Build a structured reactivation campaign for dormant patients that delivers measurable revenue within 90 days, at a fraction of the cost of paid acquisition
• Apply the five-pillar local marketing framework covering business partnerships, leveraging local resources, community engagement, corporate wellness, and educational initiatives – with specific tactics for each
• Identify and approach the right local partners across health and wellness, healthcare providers, schools, employers, estate agents, cafés, and influencers – using a structured outreach process that turns cold contacts into reciprocal relationships
• Apply the promote, convert, grow framework as a diagnostic tool to identify which pillar of their own funnel has been most under-invested and where the biggest returns are likely to come from
• Leave with three immediate actions for existing patients and three for community marketing that can be put in motion within the next 30 days without increasing the marketing budget.

The speaker

David Nelkin is the founder and CEO of Xcelerator Dental, a specialist dental marketing agency focused on practice growth.

With over 11 years of experience working with more than 200 dental practices, David is recognised as a thought leader in dental marketing. Under his leadership, Xcelerator Dental has won multiple awards, including Website of the Year at all three major dental awards in 2024 and CSR awards for sustainability initiatives.

David is passionate about simplifying the path to growth for dental practices.

Catch up on previous on-demand webinars:

• CQC registration has changed – what dental practices need to know
• ‘I need an implant mentor!’ Everything you need to know
• Your waiting list isn’t the problem. Your triage is
• Finishing your orthodontic cases: essential tips for anterior composites
• Advancing vital pulp therapy: clinical applications and predictable outcomes using MTA vpt.

You can sign up for the webinar here.

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Kerry plays roller derby, which is an intense, full contact sport. One day at roller derby practice, Kerry was practicing as the jammer – the person who scores the points. As she was coming in for a big hit, her wheel slipped in a way she did not expect. Kerry landed with all her weight coming down on her ankle.

“We decided to go to the emergency room, and we got there and they immediately told me that it was a break, not one, I had broken all of them, all three bones,” Kerry explained.

They reset Kerry’s ankle, put her in a splint and sent her home with a referral to OSMS. When Kerry got the call from OSMS, she got in right away.

“I got to OSMS and at my appointment Dr. Seiler actually took my splint off and realized that it had been extremely swollen and the splint had been too tight,” Kerry described. “So that swelling hadn’t had a chance to come down, and he needed to redo the splint, and we needed to wait another two weeks for surgery because he could not operate while it was still that swollen.”

Before and after surgery, Kerry expressed that Dr. Seiler was always there for her. She mentioned, “I felt like I was his only patient that day, which I absolutely know I was not.”

In the time after her surgery, Kerry hear a lot from OSMS, Dr. Seiler, and her nurses. They were checking in on her, making sure she was doing well.

“I just was very grateful that I felt like I knew exactly how to heal, how to get through this and make it as painless as possible,” clarified Kerry.

Unfortunately, it was Kerry’s first season when she had this injury. Kerry explained that she received a lot of feedback from people wondering why she would go back to the sport after such an injury.

“It’s such a cool group of people, and people who play this sport love this sport,” Kerry expressed. “It’s such a lifestyle. And it was really important to me to show – I have three young girls – and to show them that your life’s not over if you get hurt, you get back up and you try it again. And I didn’t want them to see me get hurt and just never go back.”

Kerry is back to doing everything she could before her injury. She stated, “It healed up really nicely. I can skate and I can move. There’s no part of it that I feel like I can’t do, and it’s been great. I don’t feel like it holds me back at all!”

Kerry’s roller derby season started in January. Before her first bout in her next season, Kerry was able to be on skates, cleared for contact, and able to play.

Thanks to OSMS, Kerry is back!

The post Kerry’s I’m Back Story: Broken Ankle from Roller Derby appeared first on Orthopedic Sports Medicine Specialists (OSMS).

A dental nurse has been erased from the General Dental Council (GDC) register after a committee found she stole approximately £240 from a practice safe.

The committee viewed CCTV footage showing the registrant, who was working as a dental nurse and member of the practice management team in 2024, accessing the safe and placing envelopes containing money in her pocket.

According to her employer, the dental nurse admitted to the theft when confronted with the video footage. In a disciplinary meeting, the registrant reportedly said: ‘I know what this is about, you don’t need to tell me.’ When asked why she took the money, the dental nurse said she did not know and offered to repay the funds.

A disciplinary summary sheet recorded that the registrant ‘expressed regret for her actions and indicated that she did not want to lose her job, offering to repay the stolen funds’.

‘Deplorable’ conduct

The registrant was immediately dismissed from her position for gross misconduct. Though her employer did not report the theft to the police, they did refer the dental nurse to the GDC in September 2024.

Finding this testimony and evidence to be reliable, the Professional Conduct Committee (PCC) imposed an immediate suspension and erased the dental nurse from the register. The committee also found the dental nurse to be unco-operative in the investigation as she did not respond to most of the correspondence sent about it. The nurse has 28 days to appeal the decision.

The PCC described the dental nurse’s conduct as ‘an abuse of her position of trust’ and said it ‘would be considered by her fellow practitioners and reasonable, informed members of the public to be deplorable’. It also found no evidence of meaningful remediation.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends. 

We hear from two online queueing specialists on what the General Dental Council (GDC) can learn from commercial ticketing software to solve bottlenecks in the Overseas Registration Exam (ORE) booking process.

Prospective candidates for the ORE have reported payment issues, errors and overloaded servers since the GDC migrated the booking system to the myGDC portal. Many were unable to book a place to sit the exam, with some unsure if they had been successful despite payment having been taken.

A Part 2 booking was delayed by a week while the GDC carried out further testing, though candidates experienced the same malfunctions regardless.

But what exactly is causing these issues? Dentistry heard from Miruna Strandberg, head of marketing at Queue-it, and Matthew King, CEO of Queue-Fair, on why the ORE booking website is failing and how the bottlenecks can be managed. Both companies provide software which helps companies cope with high volumes of website traffic.

Why does website traffic lead to bottlenecks?

According to Miruna, the problem is not simply the high volume of traffic on a website but the number of transactions they attempt.

She said: ‘Most websites can handle thousands of concurrent visitors browsing content or sitting on the homepage. It’s when those thousands of visitors start performing dynamic transactions that systems begin to struggle.’

This creates a bottleneck which fails under the transaction burden. In short, the ORE portal is not crashing due to the number of visitors on the site, but because they are all trying to book a place simultaneously.

Miruna compared this to a live event environment. She said: ‘It’s like a stadium that can hold 100,000 people. Everything works fine while people are sitting in their seats. But if everyone wants to buy a drink, use the restroom, or leave the venue at the same time, bottlenecks form quickly and the experience deteriorates.’

What exactly is causing the ORE booking bottlenecks?

Miruna described a number of different transactions within the booking process with the potential for bottlenecks:

• Checking and updating available exam places
• Processing payments
• Communicating with third-party services that detect fraud or send confirmation emails.

Any of these processes could be responsible for the webpage malfunctioning.

When attempting to determine where the problem lies, Miruna advised that the first step would be to ‘measure the system’s true capacity under realistic load conditions and understand where performance begins to degrade’.

How can bottlenecks be managed?

Miruna identified two primary ways that a bottleneck can be managed: increasing capacity or controlling traffic flow.

Capacity can be increased by ‘scaling infrastructure, re-architecting systems, redesigning business processes, or investing in additional technology’. However, she notes that this can be complex, expensive, and sometimes impractical.

Matt therefore suggested that controlling visitor flow through a virtual waiting room would be the best solution. He said this ‘should hold the visitors away from the site in the minutes leading up to the sale, and then fairly add them to the online queue when it opens’.

Miruna explained: ‘Rather than allowing thousands of visitors to overwhelm a vulnerable system at once, a virtual waiting room receives incoming traffic, provides visitors with their position in line and estimated wait time, and admits them in a fair, first-in, first-out order at a rate the booking system can reliably handle.’

Neither company has examined the GDC’s systems directly, so their comments are based on general principles rather than a technical assessment of the ORE booking platform.

What are the benefits of a queue system?

A queue system would assign candidates a random position which Matt suggests ‘eliminates unfair advantage due to (for instance) some visitors having faster internet connections than others’.

He continued: ‘People that arrive after the queue has opened are added in first-come, first-served order, but behind everyone from pre-sale so it’s all completely fair.’

According to Miruna, this would control the flow of site visitors to match capacity ‘rather than allowing demand spikes to overwhelm critical systems’.

Matt estimates that Queue-Fair’s queue system could be added to the GDC’s website in around five minutes, and that only its free tier would be required.

He added: ‘If they decided they need advanced features, or if there are many thousands of applicants, then they could upgrade to unlimited service, which starts at £150.’

Who already uses virtual waiting rooms?

Miruna also suggested monitoring traffic in real time and having contingency plans in place for unexpected demand, bot activity, or operational issues.

She said: ‘The most successful organisations combine capacity improvements with traffic orchestration strategies.’

These approaches are widely used for ticket sales at major events. Miruna said that ticket sellers ‘actively orchestrate online traffic by controlling visitor flow, filtering bots and other abusive traffic, monitoring events in real time, and managing session integrity throughout the purchase journey’.

However, queue systems have been used in educational contexts before. Queue-Fair has worked with educational establishments to manage registration day and/or results day, as well as government bodies, healthcare organisations, online retailers with busy product drops, and financial institutions.

Matt said: ‘The system is suitable for any website that gets too busy from time to time.’

Most notably, the software was used by the Royal College of Emergency Medicine for what it describes as ‘a very similar registration’ to the ORE.

The GDC has said it will implement a new candidate portal for exams taking place from 2027. It has not yet announced how the new system will manage periods of high demand.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends. 

Biosimilars have saved the U.S. health care system an estimated $50 billion since 2015, but many health care organizations have yet to fully embrace their potential.

At The Permanente Medical Group (TPMG), biosimilars have become a key strategy in delivering high-quality, affordable care. Through a physician-led approach grounded in evidence, education, and collaboration, TPMG has achieved approximately 90% adoption among eligible patients for some of the nation’s most widely used biologic medicines.

Speaking with PharmaBoardroom, Maisha Draves, MD, MPH, associate executive director of TPMG, shared how the medical group’s experience with biosimilars shows a pathway that health systems can use to expand access, reduce costs, and strengthen patient trust at the same time.

“The original journey of moving from branded to generic products took time and this will too,” said Dr. Draves. “However, as a nation we have a duty to provide affordable, high-value health care to everyone, and biosimilars are a critical part of how we do that.”

Building trust through evidence-based medicine

Rather than treating biosimilars differently from other therapies, TPMG evaluates them using the same evidence-based process that informs all clinical decisions and builds trust with patients. Physicians and pharmacists review clinical trial data, published research, and real-world evidence to determine whether a biosimilar meets the organization’s standards for safety and effectiveness.

Related clinical research story: Study: AI, genetics, and clinical data improve breast cancer risk prediction

That evaluation process is only part of the equation. Dr. Draves shared how TPMG has invested heavily in education across the entire care team — from physicians and nurses to pharmacists, infusion clinic staff, and patient service representatives. Everyone involved receives the information and resources needed to support patients, and clinical guidance is also embedded into the electronic medical record.

Involving specialists directly in the decision-making process builds trust. Each clinical specialty evaluates the evidence for itself, whether in oncology, gastroenterology, or another field. In some cases, TPMG researchers have conducted additional studies to validate outcomes in real-world practice settings.

“Our entire system moving to clinically similar medications, and being able to publish and study that evidence, has reinforced the value of this approach both within the organization and to the community at large,” said Dr. Draves.

By increasing competition among biologic therapies, biosimilars could help lower costs and improve affordability. Within Kaiser Permanente’s integrated, value-based care model, Dr. Draves emphasized that savings can be reinvested into patient care, including screenings, early detection efforts, and other services that improve population health.

What health care organizations should know about using biosimilars

Based on TPMG’s experience, Dr. Draves offered three key lessons for other health systems:

• Involve specialists who prescribe biosimilar therapies in the evaluation of the evidence and guidance of adoption decisions
• Include every member of the care team in the education process because each person plays a role in delivering safe, effective care
• Focus on the medicine itself rather than the brand; this helps clinicians and patients understand that approved biosimilars have no clinically meaningful differences from their reference products

While biosimilar adoption in the U.S. still trails many other countries, Dr. Draves sees significant opportunity ahead. Continued education, greater pricing transparency, and reduced barriers to market entry could accelerate access to these therapies and help more patients benefit from lower-cost treatment options.

As health systems nationwide look for ways to deliver greater value, TPMG’s experience shows how thoughtful innovation can benefit patients, clinicians, and communities alike.

Read the full PharmaBoardroom Q&A here.

The post How Permanente Medicine is helping unlock the promise of biosimilars appeared first on Permanente Medicine.

The post New Research Greenlights Popular Obesity Medications for High-Risk Cushing’s Syndrome appeared first on Endocrine News.

Self-employed dentists with some NHS or health service work saw taxable income rise significantly across all four UK nations in 2024/25, with Scotland recording the highest figure at £99,100.

The latest Dental Earnings and Expenses Estimates found that mean taxable income in Scotland increased by 9.3%, from £90,600 in 2023/24 to £99,100 in 2024/25.

Northern Ireland saw the largest percentage rise, with taxable income up 13.7% from £77,000 to £87,600.

In England, mean taxable income rose by 6.1%, from £78,200 to £83,000, while Wales saw a 7.7% increase, from £79,900 to £86,100.

NHS England said all four increases were statistically significant. However, it stressed that figures across the four nations are not directly comparable due to differences in dental contracts and methodology.

The report covers self-employed primary care dentists who carried out some NHS or health service work during the year. It does not include dentists who only carried out private dentistry, or dentists with employment income but no self-employed income.

The figures also include both NHS and private dentistry income, meaning the report cannot show how much taxable income came from NHS work compared with private treatment.

The headline figures combine associates and providing-performers/principals, meaning they do not show whether income changed differently for practice owners and associates. NHS England also noted that dental incorporation may affect the estimates, as income taken through salary or dividends may not be captured in the same way as self-employed income.

What do the figures show?

Taxable income is calculated as gross earnings minus total expenses, before income tax and pension contributions.

Gross earnings include self-employment income from NHS or health service dentistry and private dentistry before expenses are deducted. Expenses include tax-allowable business costs linked to both NHS and private work.

NHS England also noted that Basis Period Reform came into effect from 6 April 2024, aligning unincorporated businesses’ basis periods with the tax year. The report said employees, limited companies and any business with an accounting end date between 31 March and 5 April were unaffected.

The report said changes in the dentist population should also be considered when interpreting the figures, including a continued movement away from providing-performer and principal roles towards associate roles.

It also noted that the Dental Working Patterns Survey was not run for 2024/25. This means there is no fresh breakdown by hours worked, NHS commitment or working patterns.

Practice costs

Separate analysis from the National Association of Specialist Dental Accountants and Lawyers (NASDAL), included in the report, showed non-clinical staff wages were the largest of the listed expense categories for practices.

In England, non-clinical staff wages accounted for 21.2% of gross income in NHS practices and 19.4% in private practices.

Laboratory costs accounted for 4.1% of gross income in NHS practices in England and 6.8% in private practices, while materials accounted for 5.2% and 6.4% respectively.

NHS England said the NASDAL figures are not directly comparable with the main HM Revenue and Customs-based earnings and expenses estimates.

The report is used as evidence in remuneration negotiations and by the Review Body for Doctors’ and Dentists’ Remuneration.

Follow Dentistry on Instagram to keep up with all the latest dental news and trends.

A new two-million-pound dental practice in Weston-super-Mare has brought two established teams together under one roof, creating more capacity for patient care and new opportunities for clinicians and colleagues.

The mydentist, Gallagher Retail Park practice officially opened on 8 July 2026, welcoming patients and teams from the former Oxford Street and Beaconsfield Road practices.

The new practice has 13 surgeries, with scope for further expansion, and is now home to more than 30 colleagues, including dentists, dental nurses, receptionists, treatment coordinators and managers.

Many members of the team have worked within the local practices for more than a decade. Their move to mydentist, Gallagher Retail Park means patients can continue to see familiar clinicians and colleagues while benefiting from a larger, more modern practice.

For practice manager Chelsea Pearce and her team, the opening marks the culmination of a significant period of planning and change.

‘This fantastic new practice has allowed us to increase our dental surgery capacity and the size of our team, which in turn means more care can be delivered to the community,’ Chelsea commented.

‘We look forward to welcoming patients into the new practice and delivering affordable care to the community of Weston-super-Mare, so they can continue to access the vital dental care they need.’

More capacity and greater choice for patients

The move has addressed several of the practical limitations associated with the former practices. The larger premises provide more space for patient care, improved accessibility, free parking and dedicated disabled parking spaces. Teams also have more room to work together and support a wider range of treatments.

The practice provides NHS dentistry alongside myoptions, mydentist’s affordable private offering, and premium private dentistry. Treatments available include dental implants, clear aligners, endodontics and cosmetic dentistry.

A newly appointed endodontist has also joined the team, allowing more patients to access advanced root canal treatment within the practice.

The site is supported by digital workflows and technology including CBCT scanning, while dedicated treatment coordinator rooms give patients a private space to discuss their treatment options.

John Hudson, property director at mydentist, said the new environment had been designed around the needs of both patients and practice teams.

‘We’re thrilled to open mydentist, Gallagher Retail Park, our new state-of-the-art practice in Weston-super-Mare,’ he commented.

‘The new premises offer improved facilities for our dedicated practice teams, as well as more choice for our patients. With scope for further expansion in future, we will be able to provide an increased level of support for patients in the local community.’

Creating opportunities for clinicians and colleagues

The investment represents more than an increase in surgery capacity. It also creates an environment in which clinicians and colleagues can work across a broader range of services, use modern technology and learn from team members with different areas of expertise.

For clinicians, this may provide opportunities to develop particular clinical interests, gain experience in different treatments or work alongside colleagues providing advanced care.

Dental nurses may be able to support a wider range of procedures, build additional skills or work towards further qualifications. As the practice grows, new opportunities may also emerge in treatment coordination, leadership and practice management.

Career development will not look the same for every team member. For some, it may mean pursuing a specific area of dentistry. For others, it could involve gaining confidence, taking on additional responsibility or finding a working pattern that better fits life outside work.

Teams at mydentist, Gallagher Retail Park can also draw on the support of mydentist’s wider UK network, including experienced clinical teams, established development pathways and opportunities across more than 500 practices.

Part of a wider programme of investment

The new mydentist, Gallagher Retail Park site is the latest in a series of major projects across the mydentist estate.

In recent years, the organisation has invested in new and expanded practices in locations including Wakefield, Cardiff, Walsall, Berkhamsted, Chesterfield and Kirkby.

Each project is shaped by the needs of the local practice, its patients and the surrounding community. Some involve bringing established teams together in larger premises. Others focus on adding surgeries, introducing new technology or creating space for a broader range of treatments.

The aim is not simply to replace one building with another. It is to create practices with the capacity, facilities and working environments needed to support sustainable growth and long-term patient care.

In Weston-super-Mare, that investment has brought two long-established teams together, increased the number of surgeries available and expanded the range of care patients can access locally.

Careers at mydentist

Behind every new or expanded practice are the clinicians and colleagues who deliver patient care each day.

Investments such as mydentist, Gallagher Retail Park are designed to give teams the environment, technology and support they need to develop their skills and build rewarding careers.

Throughout its UK network, mydentist offers a variety of opportunities across clinical, practice and support centre roles. To learn more about life at mydentist and explore current vacancies, visit the mydentist Careers website at www.mydentist.co.uk/careers.

This article is sponsored by mydentist.

Nigel Jones contrasts decades of stagnant NHS contract debates with the tech-driven growth mindset thriving across private dentistry.

It’s such a strange uncertain world at the moment, which presents a challenge to someone who has responsibility for shaping Practice Plan’s strategy for the next five years. 

In fact, the chances are that since I started typing that sentence, Donald Trump has posted again on Truth Social, and the world has changed again!

Such volatility has changed the nature of modern business strategy from predicting and planning for a reasonably certain future environment to being about putting yourself in a position to respond, quickly and successfully, to an increasing amount of unanticipated change.

So, does that also apply to dentistry and to the dental profession?

Well, in the past few weeks, via my attendance at two major dental events, I’ve had a reminder that both the old and the new strategic approaches are still very much in play.

The stagnant NHS debate

Take, for example, the British Dental Conference and Dentistry Show where I was privileged to host a panel discussing the NHS contract reforms, principally in England although touching on what is happening in Wales.

I’ve now been to more than 30 British Dental Association conferences since my ‘debut’ in 1990 and a continuous thread of conversation through all those events has been what to do with NHS dentistry. 

Of course, it could be argued that lots has changed in the intervening period, and I don’t just mean the contractual changes introduced in April.

Devolution creating four versions of NHS dentistry, the introduction of units of dental activities and fixed contract values in England and Wales, flexible commissioning, I could go on.

But, for me, it was striking that the fundamental topics we were addressing on this year’s panel – contractual frameworks, adequate funding and NHS workforce – were essentially the same as the issues being debated in 1990.

Indeed, one member of the panel audience complimented me on my ability to still look, and sound, interested in the same old debates that have been held for decades!

While I get the sentiment behind the observation, of course I’m interested. How can you not be when the mental health of the profession is so negatively impacted by NHS dentistry and when oral health inequality appears to be widening at an alarming rate? 

For those reasons, the snail-like pace of real change, despite Conservative, New Labour, a coalition and the current Labour governments, is immensely frustrating. 

To be forced to reiterate the same old arguments decade after decade does not exactly point to the volatile ever-changing world I described in my opening paragraphs.

A tale of two mindsets

However, compare that with the event that I attended most recently, hosted by Practice Plan, for predominantly private dentists with the aim of creating a safe, supportive community of like-minded individuals.

The talk was rarely about business or clinical matters, but when it was, the contrast with the understandably low morale and resigned feel to the audience attending the panel at the Dentistry Show was stark.

If ever you wanted a real-life demonstration of the difference between a fixed and growth mindset, this was it.

To hear many practice owners talking so enthusiastically about their investment in their teams, in new clinical skills, in new technology, in management information systems and in sustainability was incredibly motivating. Of course, it’s not all a bed of roses but my point is that the mood perfectly encapsulated that strategic requirement to be able to adapt and constantly evolve.

Capitalising on future opportunities

To be fair, at the British Dental Conference and Dentistry Show, it was also not hard to find plenty of evidence of similar positivity.

For example, take the panel discussion at Practice Plan’s Dental Business Theatre about the tech-powered patient journey with its amazing contributions from dental business consultant Mike Bentley and Boxly co-founder Adam Smith as well as two of the most forward-thinking practice owners in UK dentistry, Kish Patel and Jin Vaghela.

Their optimism about the future, however volatile it may be, was infectious.

So, while it might be a strange and unpredictable world, not just now, but for the foreseeable future, the way to deal with it is to put yourself in a position where you have the energy and the time to proactively capitalise on the wealth of opportunity, partners and new technology out there.

This article is sponsored by Practice Plan.

The post CMS Releases Annual Physician Payment Proposed Rule; Physician Payment Reform Legislation Introduced in the House  appeared first on Endocrine News.

The post Benefits of Smart Purchasing first appeared on My Green Doctor.

The government has launched a call for evidence on protecting the title ‘nurse’ in law, while recognising that established roles such as dental nurse may need exemptions.

Dental nurse is already a protected title under the Dentists Act 1984, and dental nurses must be registered with the General Dental Council (GDC) to use it. However, the government is now considering wider protection for the title ‘nurse’, raising questions over how exemptions for regulated roles such as dental nurse should be written.

The Department of Health and Social Care (DHSC) opened the 10-week call for evidence that will close at 11:59pm on 8 October 2026.

The government wants to make it a criminal offence for someone who is not registered with the Nursing and Midwifery Council (NMC) to call themselves a nurse.

Currently, the title ‘registered nurse’ is protected in law, but the wider title ‘nurse’ is not. The government said this could mislead patients and the public if someone uses the title without being qualified, registered or entitled to present themselves in that way.

Future protection

However, the call for evidence acknowledges that the word is already used in several established professional titles, including dental nurse.

The government said it does not intend to criminalise legitimate uses of the word ‘nurse’ in these contexts. It said any future protection is likely to require carefully defined exemptions where the title is well established, the role is distinct from NMC registrants and there is limited risk of public confusion or harm.

While dental nurses are already regulated dental care professionals, the profession is still encouraged to respond to ensure the title is clearly protected from unintended consequences.

The government is seeking views from individuals, employers, regulators, professional bodies, trade unions and other sectors where ‘nurse’ is used as part of a professional title. Responses must be submitted through the online survey.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

The New Workbook 8: Resilience Planning 
My Green Doctor has just launched our long-anticipated Workbook 8 on the topic of resilience planning. Outpatient healthcare organization must consider their own operational resilience. Disasters may come from severe storms, extreme heat, wildfire smoke, floods, electrical grid failures, or even threats from visitors to your building. Disruptions can be expensive, time-consuming, and dangerous to health. Resilient practices protect their property and continue serving their communities during or shortly after a disaster. Resilience planning keeps a threat from becoming a disaster!

Workbook 8 is here is for outpatient clinics, practices and other facilities to strengthen resilience while improving patient outcomes. Practice managers and administrators worldwide have never had such as a practical, step-by-step guide as this new Resilience Planning workbook (https://mygreendoctor.org/workbook-8-resilience-planning/). Contact one of our expert sustainability coaches for help adding this essential tool to your operational plans: member.services@mygreendoctor.org .

References

1. Gould CF, Heft-Neal S, Johnson M, et al. Health Effects of Wildfire Smoke Exposure: A Systematic Review and Meta-Analysis. Annual Review of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC12183787/
2. Zhang Q, Wang Y, Xiao Q, et al. Long-range PM2.5 Pollution and Health Impacts from the 2023 Canadian Wildfires. Nature. 2025. https://doi.org/10.1038/s41586-025-09482-1

The post The New Workbook 8: Resilience Planning first appeared on My Green Doctor.

Wildfire Preparedness Is Healthcare Preparedness
Wildfires are no longer just a concern for communities near forests or grasslands. Today, wildfire smoke has become a widespread public health issue that can affect patients hundreds or even thousands of miles from an active fire. For primary care practices and for certain specialties such as geriatrics, pulmonary, and cardiology, preparing for wildfire season is no longer optional. It is an important part of being a resilient practice.

Smoke from wildfires contains fine particulate matter (PM2.5) that can penetrate deep into the lungs and enter the bloodstream. Exposure has been linked to worsening asthma, chronic obstructive pulmonary disease (COPD), cardiovascular disease, diabetes, pregnancy complications, and other chronic medical conditions. A recent systematic review also found that wildfire smoke exposure is associated with increased respiratory hospitalizations and higher mortality.

What are the challenges for healthcare?

The challenge for healthcare professionals is that patients often underestimate their risk. Many assume that if they cannot see flames nearby, they are safe. However, research from the record-breaking 2023 Canadian wildfires demonstrated that smoke traveled across North America and even reached Europe, exposing hundreds of millions of people to unhealthy air quality. The health impacts of wildfire smoke are not limited by geography.

How to be prepared and proactive

Fortunately, preparedness does not require expensive new programs. It begins with practical planning and proactive patient education.

As wildfire season approaches, healthcare teams can use their staff meeting to review asthma and COPD action plans. Part of your plans should be for physicians and nurses to encourage patients to follow every day the local Air Quality Index (AQI) and to provide them the free link: https://www.airnow.gov/aqi/aqi-basics/. Clinics can recommend that patients remain indoors during smoke events, recommend high-quality indoor air filtration in the home, and check that vulnerable patients have adequate supplies of rescue inhalers before poor air quality develops. These conversations are particularly valuable for children, older adults, pregnant women, and patients living with chronic respiratory or cardiovascular disease.

Healthcare organizations should also consider their own operational resilience. Wildfire smoke events can disrupt normal clinic operations, making preparedness essential for maintaining continuity of care. Reviewing HVAC maintenance schedules, evaluating indoor air filtration systems, expanding telehealth capabilities, developing communication plans for high-risk patients, and educating staff about smoke-related health risks can help practices continue serving their communities during prolonged smoke events.

These actions represent more than emergency planning. They are part of building healthcare resilience. A resilient practice anticipates changing conditions, prepares in advance, and continues providing safe, high-quality care even during environmental challenges. As wildfire seasons become longer and more intense, healthcare organizations that prepare today will be better positioned to protect both patients and staff tomorrow.

Free Patient Education Resources

My Green Doctor offers a library of free state-of-the-art waiting room brochures for your patients covering a dozen topics, including our brochure, “Air pollution and Wildfires in a Changing Climate: Protecting Your Family.”  These can be read on a computer or smart phone using a URL link or by the QR code that you can give to patients and families. Most are provided in English, Spanish, and Chinese. You are welcome to print these yourself or purchase them economically by emailing My Green Doctor. For Entire Practice Green members, new orders come with a complementary six-brochure display stand for the waiting room. This is about protecting your patients and their families!

Waiting Room Brochures:
https://mygreendoctor.org/resources/waiting-room-brochures/

References

1. Gould CF, Heft-Neal S, Johnson M, et al. Health Effects of Wildfire Smoke Exposure: A Systematic Review and Meta-Analysis. Annual Review of Medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC12183787/
2. Zhang Q, Wang Y, Xiao Q, et al. Long-range PM2.5 Pollution and Health Impacts from the 2023 Canadian Wildfires. Nature. 2025. https://doi.org/10.1038/s41586-025-09482-1

The post Wildfire Preparedness for Healthcare first appeared on My Green Doctor.

The wait is over. The Dentistry Top 50 2026 has arrived, celebrating the people whose work, leadership and ideas are helping to shape the future of UK dentistry.

Nineteen people join the Top 50 for the first time this year, alongside returning figures who continue to make their mark on the profession. The list spans every corner of dentistry, from clinicians transforming patient care and educators inspiring the next generation, to researchers advancing knowledge, campaigners driving change and leaders shaping national policy.

Compiled after weeks of nominations, discussion and deliberation, the list reflects the many different ways influence is earned in modern dentistry. Some names will be familiar, having featured in previous years and continued to build on that impact. Others have emerged through new ideas, fresh leadership or achievements that have caught the profession’s attention over the past 12 months.

There is no ranking involved. What unites everyone on this year’s list is a shared commitment to improving dentistry for colleagues, for patients and for the wider profession.

Recognising excellence

Putting the list together is never straightforward. Nominations arrived from across the profession, each one making the case for someone whose work deserved recognition. Narrowing hundreds of names down to 50 meant weighing achievements that are often impossible to compare directly.

A campaigner’s impact does not look like a researcher’s, and a practice leader’s contribution does not look like an educator’s. The final list is an attempt to recognise excellence in all its different forms.

This was my first time being part of the Top 50 selection process, and what struck me most was the care that went into every discussion. Every nomination represented someone making a genuine difference to the profession, which made every decision both rewarding and incredibly difficult. While not everyone could make the final 50, this year’s list reflects the breadth of talent, leadership and innovation that continues to shape the future of UK dentistry.

This year’s Top 50 is delivered in partnership with Denplan.

‘Having the opportunity to be part of the Dentistry Top 50 campaign has been a real privilege,’ said Matthew Nolan, head dental officer at Denplan, said:

‘Reading through this year’s list, I have been struck not only by the quality and breadth of talent across the profession, but by the commitment, energy and determination of so many individuals who are working to make a genuine difference. These are people who are challenging thinking, supporting colleagues, inspiring the next generation and helping to shape a thriving future for UK dentistry. Congratulations to everyone that made the list.’

Explore the Dentistry Top 50 2026 below, and discover the people whose work is helping to define the profession today.

A-D

E-J

K-M

N-R

S-Z

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

Thanks to engaging social media content, dentist Emi Mawson is simplifying the complex, debunking myths and empowering patients everywhere amid the digital age’s overwhelm.

As @dentist_emi, Emi Mawson is captivating a growing audience of 92k on TikTok and thousands more on Instagram with her vibrant approach to dental care. Passionate and dedicated, she transforms expert advice into fun, easy-to-understand content. Whether she’s dispelling myths about veneers or unravelling NHS reforms, her goal is to inspire patients to pursue brighter (but, more importantly, healthier) smiles.

Posts such as ‘Your face shape should dictate your tooth shape in cosmetic dentistry. Not everyone suits every style!’ garnered 736.9k views whilst ‘Vaping and oral cancer’ reached 442.7k people. ‘Scary things about oral cancer that are literally burned into my brain’ resulted in 620.7k views and her ‘How to lose your teeth in 10 ways’ an audience of 139k. The numbers are impressive; the titles irresistibly catchy.

As such, Emi is building a dedicated following by tapping into the zeitgeist of our times – digital connectivity, the rise of Gen Z values, the demand for brand transparency and the push to correct misinformation. By focusing on trending health issues that resonate and using relatable language, Emi believes social media is a powerful tool for patient education.

The new search engines

She explains: ‘Instagram and TikTok have become the new search engines; it is where many people spend most of their time, and a reel or post can be viewed an infinite number of times. It is a great way to distribute information without it being time-consuming. The average dentist might see 15 to 25 patients in a day, and we find ourselves repeating the same tasks, so this significantly increases our reach.

‘Communication matters in the current dental health landscape. Too many people lack access to dental care, so offering free, easy-to-access preventive advice helps equip them to care for their mouths and be more proactive about their oral health. As professionals, it is therefore important to have a presence on these platforms because many trends go viral, and it’s helpful for patients to have reliable sources who can fact-check and ensure everyone receives accurate information.’

So, how does she choose topics that best resonate with her followers?

She jokes: ‘I can’t read an academic paper without finding a nugget of information I want to share with the world.’ She frequently receives questions from followers in her DMs and is often prompted to correct misinformation in a viral post. Emi says: ‘There may be a hot topic people are talking about, and I want to weigh in. I like to keep it very, very topical.’

In December, she carefully broke down the new NHS dental reforms into quick, digestible points on TikTok, recognising that the details were complex. Her punchy bullet-point style made headlines, won followers and showcased her easy-to-grasp approach.

‘There’s a lot going on in the news about dentistry, including government policies that most people don’t have time to research. I make it my job to analyse a piece of news and explain how it will affect them in the real world. I’ve got a list of topics on my phone, and I can’t keep up with the number of videos I want to make and the amount of content I want to create. So I really do find inspiration everywhere.’

Cutting through oral health confusion

Whilst knowledge empowers patients, the proliferation of oral health options on shop shelves and online can be problematic. So does she think patients are often overwhelmed by the market? If so, are they in need of a trusted source for guidance on which products work, for whom, and which don’t and shouldn’t be used?

‘The oral health market is saturated, and walking through the supermarket aisles reveals just how confusing it can be, with many brands making different claims. Online, I often see products being used incorrectly or people relying too heavily on a single product to address their dental issues. Therefore, it’s important to provide education on this topic.

‘Whether it’s the trend of using charcoal toothpaste or the abrasive ingredients in whitening pastes that can be harmful over time, we need to share our expertise to help simplify product use and highlight things people may not know, but that could benefit their oral health.’

Skincare for the gums

Emi’s recent ‘Underrated dental products that are actually worth the hype!’ list was a treasure trove of oral health tools for anyone seeking at-home hygiene tips. With 37.6k views, Emi’s TikTok listed ‘Five products I wish more people knew about, but you probably haven’t heard of’, lifting the curtain on her professional insight.

Among the products she says she is ‘always recommending to my patients’ was Gengigel, a gingival gel containing hyaluronic acid that helps repair and hydrate, and that she cleverly marketed as ‘skincare for the gums’.

Emi explains: ‘Although not widely known, Gengigel can be a valuable addition to any oral health routine, and I wanted to spotlight it alongside other must-haves. Its hyaluronic acid-based formula is gentle and microbiome-friendly, genuinely supporting healing and comfort. It’s especially beneficial for dry mouth, which can occur during hormonal fluctuations such as pregnancy, the postpartum period, and menopause, and is a common side effect of many medications.

‘Because it is an effective way to rehydrate the gums and promote healing, I also recommend it to patients who have undergone extractions or surgery to aid recovery. New brace wearers may find it helpful, particularly if they experience gum irritation. It’s also suitable for patients with periodontal disease, or who are undergoing complex perio treatments.’

Information at pace

In a world where everything is immediate and people expect instant results, Emi is happy to meet these expectations by providing information at a pace.

‘Social media allows us to respond to misinformation quickly but also address controversial topics in a generic way without a patient feeling criticised or under attack. Most importantly, it enables patients (even those who are not my own) to take ownership and learn healthy habits.’

However, in her treatment approach, she believes that only by slowing down and ensuring a solid foundation of overall health before moving on to anything else can she deliver optimal smile aesthetics.

‘While I recognise the benefits of fast, easy access to evidence-based information, once in the chair, my patients receive the gift of time and a tailored approach to their smile health. Communication and understanding are vital to any smile makeover journey and essential to the planning process. Good planning requires time to understand the destination and where you, as a clinician, expect to end up, and to ensure that is exactly what the patient wants, too.

‘You have to establish that the patient understands what is required of them, while always taking a “health first” approach. We must respect the biology and support our patients in reaching their goals before we can proceed to the exciting cosmetic treatment. Whether speaking to patients face-to-face or online, I aim to inspire and empower people to care for their oral health and get the most from their dental care. Having an online voice is part of this approach, and I plan to continue showing up to ensure people are armed with the best advice to optimise their oral health.’

This article is sponsored by Dentocare.

The post The Endocrine Society Endorses National Strategy to Close the Women’s Health Gap  appeared first on Endocrine News.

A large US trial has found that silver diamine fluoride can arrest tooth decay in more than half of affected baby teeth when applied every six months.

The Phase III study, published online in JAMA Pediatrics, included 830 children under the age of six with severe early childhood caries. Researchers tested 38% silver diamine fluoride (SDF), a low-cost liquid applied directly to cavities without drilling, injections or sedation.

At six months, 54.0% of lesions treated with SDF had arrested, compared with 22.5% in the placebo group. At eight months, arrest rates were 50.2% for SDF and 17.4% for placebo.

The authors said the findings provided evidence that could support a future Food and Drug Administration (FDA) application for SDF as a treatment for dental caries in children.

Margherita Fontana, professor of dentistry at the University of Michigan School of Dentistry and lead investigator, said the treatment was effective and safe, including in children as young as one.

Researchers said SDF could be particularly useful for very young children, patients with dental anxiety, people with developmental or physical disabilities and those with limited access to conventional dental care.

However, SDF has a visible drawback, with the silver permanently turning the decayed part of the tooth dark.

SDF usage in UK dentistry

While the study was designed to support a US FDA application, the findings will also be of interest to UK clinicians using SDF as part of minimally invasive caries management, particularly for young children and patients who may struggle with conventional restorative treatment.

Amr Moursi, professor of paediatric dentistry at New York University College of Dentistry and co-principal investigator, said: ‘Our results support FDA approval of SDF for managing arrest of tooth decay in young children.’

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

Dr Pretam Gharat explores the indications, placement technique, anatomical considerations and potential complications of pterygoid implants.

Pterygoid implants represent an effective fixed implant treatment for the atrophic posterior maxilla. They provide a highly stable, fixed alternative for treating a severely resorbed maxillary jaw without complicated bone grafting procedures. By anchoring directly into the dense, non-resorbing D1 cortical bone of the pterygoid process of the sphenoid bone, they bypass the need for sinus lifts in majority of cases (subject to anatomy).

In combination with zygomatic, trans-sinus and trans-nasal implants, they constitute the foundation of the Maxilla-For-All treatment concept for severe maxillary atrophy. (https://jdentalcare.com/en/maxilla-for-all-treatment-concept/)

The pterygoid implant is the first implant utilised in the PATZi protocol, which is a systematic algorithm for maxillary full arch implant treatment planning that addresses intra-operative surprises (Ponnusamy S et al, 2023).

Indications of pterygoid implants

1. Additional support

Pterygoid implants will increase the A-P spread in a full arch rehabilitation. Increasing the A-P spread (the distance from the anterior most implant to the posterior most implants) provides critical stability, reduces cantilever length and prevents mechanical failures like screw loosening.

2. Increase cumulative torque value and thereby facilitate immediate load

Pterygoid implants usually anchor into the dense basal cortical bone (D1) of the pterygoid plates or pyramidal process which provides the ideal conditions for high insertion torques. This helps increase the cumulative torque across the arch and enables the clinician to immediately load the implants in a full arch situation (Jensen et al 2012, Papaspyridakos P et al 2014).

3. Avoid sinus lifts

In posterior edentulous spaces, we could place Pterygoid implants most times bypassing the sinus, thereby avoiding sinus lifts. This makes the process faster and less complex.

4. Improves A-P spread

The position of Pterygoid implants improves the A-P spread. This is biomechanically favourable for full arch prosthetics.

5. Eliminates cantilevers

SkalakY (1983) theorised that during cantilever loading, the best force distribution could be achieved by spreading out the maximum number of abutments as much as possible. According to his theoretical construct, he believed that this would decrease the load per implant as much as possible.

6. Alternative to Zygomatic implants

Since they are positioned far back in the arch near the maxillary tuberosity, they provide a stable posterior support for a full-arch bridge and may negate the use of zygomatic implants; which could be used, if necessary, in the future.

7. Rescue implant

If all other anchorage options in the posterior maxilla have been exhausted, pterygoid implants could quickly salvage a failing posterior or angled conventional implant without requiring complex bone grafting or sinus lift surgery and provide a very stable posterior support for a full arch bridge even provide immediate load.

Anatomical pathway and placement

The path

The implant passes through the maxillary tuberosity and the pyramidal process of the palatine bone before deeply engaging the pterygoid process.

Angulation

They are typically inserted at a 30 to 45-degree angle relative to the occlusal plane to bypass the maxillary sinus and maximise contact with dense Type I bone of the pyramidal process.

Medio-lateral angulation pointing towards the hamular notch.

One Hour marker medial – as shown in the image. Average angulation is nine to 33 degrees.

Bicortical/multi-cortical anchorage

Engaging these dense structural plates yields high initial torque (often over 60 Ncm), which can allow for immediate functional loading.

JD Pterygo retractor

JD Pterygo Retractor is a phenomenal tool designed to make the placement easier for  beginners.

Surgical and anatomical complications (including, but not limited to)

Haemorrhage

Bleeding from the greater palatine artery or pterygoid venous plexus due to the dense local blood supply. This is thankfully rare due to anatomical position of the blood vessels.

Implant misplacement

Angular deviations leading to failure to engage the pterygoid cortical bone or accidental perforation of the internal pterygoid plate.

Nerve injury and paresthesia

Temporary or permanent sensory disturbances affecting local palatine and maxillary branches.

Trismus

Restricted mouth opening or muscle spasms post-surgery. This has also been reported to be transient.

Tuberosity fracture

Mechanical fracture of the bone if placement is positioned excessively distal.

Conclusion

Placement of pterygoid implants is an extremely viable solution in rehabilitating posterior atrophied maxillae due to their high insertion torques and increase A-P spread. They have exhibited an excellent long term survival rate. Bone loss level around the implants when compared was in line with that of conventional implants, making them a viable treatment modality in immediate full arch load situations (Marco R et al, 2026).

Bibliography

• https://jdentalcare.com/en/maxilla-for-all-treatment-concept/ 24.07.2026 1300hrs GMT
• Ponnusamy S, Gonzalez J, Holtzclaw D. A Systematic Approach to Restoring Full Arch Length with Maxillary Fixed Implant Reconstruction: The PATZi Protocol. Int J Oral Maxillofac Implants. 2023 Oct 17;38(5):996-1004. doi: 10.11607/jomi.10153. PMID: 37847841.
• Jensen OT, Adams MW. Secondary stabilisation of maxillary m-4 treatment with unstable implants for immediate function: biomechanical considerations and report of 10 cases after 1 year in function. Int J Oral Maxillofac Implants. 2012
• Benic G. I., Mir-Mari J., Hämmerle C. Loading protocols for single-implant crowns: a systematic review and meta-analysis. The International Journal of Oral & Maxillofacial Implants. 2014;29:222–238. doi: 10.11607/jomi.2014suppl.g4.1
• Papaspyridakos P., Chen C.-J., Chuang S.-K., Weber H.-P. Implant loading protocols for edentulous patients with fixed prostheses: a systematic review and meta-analysis. The International Journal of Oral & Maxillofacial Implants. 2014;29:256–270. doi: 10.11607/jomi.2014suppl.g4.3
• Skalak R. Biomechanics considerations in osseointegrated prostheses, J Prosth Dcnt 1983;49:843-848
• Tommaso Grandi, Paolo Toti, Cesare Paoleschi, Matteo Giorgi, Ugo Covani and Giovanni Battista Menchini-Fabris, J. Clin. Med. 2025, 14(10), 3544 DOI: org/10.3390/jcm14103544
• Raouf K, Chrcanovic BR Clinical Outcomes of Pterygoid and Maxillary Tuberosity Implants: A Systematic Review. J. Clin. Med. 2024, 13(15), 4544
• Raouf K, Chrcanovic BR Clinical Outcomes of Pterygoid and Maxillary Tuberosity Implants: A Systematic Review. J. Clin. Med. 2024, 13(15), 4544
• https://www.prosthodontics.org/about-acp/position-statement-use-of-implants-in-the-pterygoid-region-for-prosthodontic-treatment-/ 25.07.2026 1400hrs GMT
• Broumand, V., Kirchhofer, J. Pterygoid implants as alternative to bone augmentation in implant dentistry. Br Dent J 238, 99–109 (2025). https://doi.org/10.1038/s41415-024-8274-y
• Marco Roy, Luigi Angelo Vaira, Barbara Dorocka Bobkowska, Pterygoid implants, a graftless alternative solution to rehabilitate posterior maxillary atrophy: A retrospective analysis, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology, Volume 38, Issue 5, 2026,Pages 897-901

This article is sponsored by Dr Pretam Gharat Dental Implants.

Artificial intelligence is transforming healthcare. That statement is no longer controversial. AI is already being used to summarize clinical encounters, identify documentation gaps, suggest codes, flag claims for review, predict denials, and support utilization-management decisions.

The controversy begins when AI is marketed as something it is not: an infallible replacement for the people who understand medicine, documentation, coding, billing, compliance, and the law.

The most dangerous version of that marketing is the claim that an insurer, working with an AI vendor, can “legitimately” deny 60 percent of provider claims. That assertion should be treated with extreme skepticism. It is not a self-proving measure of accuracy, medical necessity, fraud, or improper billing. At best, it is an unexplained performance statistic. At worst, it is a sales pitch dressed up as science.

“A denial is not the same thing as a correct denial. A prediction is not a finding. A statistical outlier is not fraud. And algorithmic output is not a legal conclusion.”

AI has an important place in healthcare. It can reduce administrative burdens, improve consistency, identify patterns, and help professionals focus their time where it matters most. But AI remains a tool. It requires human interaction at the front, middle, and end of the process. That will remain true for the foreseeable future.

AI will not honestly replace auditors, billers, or coders. It will change how those professionals work. It will eliminate some repetitive tasks and increase the value of others. But the accountability, reasoning, judgment, and professional skepticism that these roles require cannot be reduced to tokens, probabilities, or a denial percentage.

The “60 Percent” Denial Claim Is Not What It Pretends to Be

The first question should be simple:

Sixty percent of what?

There is a substantial difference between:

• 60 percent of all claims submitted
• 60 percent of claims selected for an unusually aggressive audit
• 60 percent of claim lines flagged for additional review
• 60 percent of claims containing a documentation discrepancy
• 60 percent of claims that an algorithm predicts will be denied
• 60 percent of claims ultimately determined, after complete human review, to be unsupported
• 60 percent of claims that are actually and lawfully denied after considering the medical record, applicable coverage policy, coding rules, authorization requirements, and provider response

Those are not interchangeable categories. Treating them as equivalent is the first fallacy.

A model can identify claims that are expensive, unusual, inconsistent with historical patterns, or different from a payer’s preferred utilization profile. None of those characteristics proves that the claim is improper.

The number also says nothing about:

• False positives: How many legitimate claims did the system flag?
• False negatives: How many improper claims did the system miss?
• Appeal outcomes: How many denials were reversed?
• Human review: Did a qualified reviewer examine the complete record?
• Data quality: Was the model working from the full clinical and billing record?
• Denial definitions: Was a technical edit treated as a substantive denial?
• Claim-line inflation: Were individual services counted as separate “claims”?
• Model drift: Does the reported performance still exist after the patient population, providers, codes, or policies change?

A denial algorithm can achieve an impressive percentage by being aggressively wrong. If the system flags nearly everything, it may produce a high number of denials while providing very little information about whether those denials are correct.

That is not efficiency. It is the industrialization of suspicion.

Why the 60 Percent Assertion Is a Fallacy

1. Historical payment patterns are not medical necessity

AI systems learn from historical data. Historical data reflects prior human decisions, payer policies, provider behavior, documentation practices, regional practice patterns, and sometimes historical bias.

If a payer historically denied a category of service, an AI model may learn that the category is “likely to be denied.” That does not establish that the service was medically unnecessary. It may only establish that the payer has a history of denying it.

A model trained to predict payer behavior can become very good at predicting payer behavior without becoming good at determining what care was appropriate.

2. Medical records are contextual, not merely transactional

Healthcare documentation is not a collection of isolated keywords. It is a narrative that develops over time.

The significance of a symptom may depend on:

• The patient’s history
• The progression of the condition
• Failed conservative treatment
• The physician’s differential diagnosis
• Examination findings
• Diagnostic testing
• Comorbidities
• Risk factors
• Response to prior treatment
• The clinical judgment exercised at the time of care

An algorithm may identify that a particular code is absent. It may not understand why the code was absent, whether another portion of the record supplies the necessary support, or whether the documentation reflects a clinically reasonable decision under the circumstances.

3. Coding is governed by rules, not just pattern recognition

Coding requires more than matching words to codes. It requires interpretation of official guidelines, payer rules, sequencing requirements, modifiers, global-period concepts, bundling edits, medical-necessity policies, and the relationship between documentation and the service reported.

A code suggestion is not a code determination.

A system may recommend a code that appears statistically likely but is inconsistent with the operative report, the level of service, the applicable coding guidelines, or the provider’s actual work. Conversely, it may fail to recognize legitimate complexity because the relevant facts are expressed in ordinary clinical language rather than in the precise terms on which the model was trained.

4. Missing data is not negative evidence

One of the most common errors in automated review is treating an absent data element as proof that the underlying fact did not exist.

The absence of a phrase from a claim form does not necessarily mean the absence of the fact from the medical record. The absence of a code does not necessarily mean the absence of a diagnosis. The absence of an authorization number does not necessarily mean that authorization was not obtained. The absence of a structured field does not necessarily mean the clinical event did not occur.

AI systems are particularly vulnerable when data is fragmented across:

• Electronic health records
• Scanned records
• Operative reports
• Laboratory systems
• Referral platforms
• Authorization portals
• Payer correspondence
• Appeals files
• Separate provider locations

A model that reviews only what is convenient to retrieve may produce a confident conclusion from an incomplete record.

5. Denial policies are not the same as clinical truth

An insurer’s coverage policy is not necessarily a complete statement of medical truth. It is a contractual, regulatory, or business rule governing payment.

A service can be clinically appropriate even when a payer disputes coverage. A service can be supported by the record even when a payer applies a narrow interpretation of its policy. A provider can comply with professional standards even when the claim requires an appeal.

The model must not be allowed to convert “the payer does not want to pay” into “the provider was wrong.”

6. AI may reproduce payer bias

If the training data reflects aggressive utilization management, the model may reproduce and amplify that conduct.

Bias can enter through:

• Incomplete representation of patient populations
• Historical underdiagnosis
• Unequal access to specialty care
• Geographic practice differences
• Provider-type assumptions
• Socioeconomic proxies
• Language differences
• Documentation-style differences
• Race, disability, age, or gender proxies
• Feedback loops created when prior denials become future training data

A patient who receives more intensive care because of complex comorbidities may look to a model like an outlier. A safety-net provider may appear inefficient because the provider serves a population with greater clinical and social needs. A specialist may appear expensive because the specialist treats difficult cases.

Those are not legitimate reasons to deny medically necessary care.

7. A model cannot independently determine causation

Healthcare billing frequently requires a determination of why a service was provided and how the service relates to the patient’s condition.

That is a causal question, not merely a predictive question.

A model may identify that a procedure often follows a particular diagnosis. It may not be able to determine whether, in this patient’s case, the procedure was performed because of that diagnosis, because of a complication, because of a failed prior intervention, or because of a clinical circumstance that does not fit the dominant pattern.

8. The model may be optimized for the wrong objective

An insurer may measure success by:

• Reduced claim payments
• Reduced utilization
• Increased denial rates
• Shorter review times
• Lower administrative costs; or
• Fewer paid claim lines

Providers, patients, and clinicians may measure success by:

• Accurate payment
• Timely access to care
• Appropriate treatment
• Patient safety
• Correct coding
• Regulatory compliance
• Resolution of legitimate disputes

Those objectives are not identical. A model optimized to reduce payments may perform exactly as designed while producing unacceptable clinical and legal outcomes.

9. Appeals expose the weakness of automated certainty

A denial that is never appealed may be counted as a successful denial even though the provider lacked the time, resources, or information to challenge it.

Prior-authorization research has documented the substantial burden that payer review places on physicians and practices. The American Medical Association’s 2024 prior-authorization survey reflects the continuing administrative burden and the need for reform. A system should not be judged solely by how many denials it produces when many providers cannot realistically appeal every incorrect decision.

The meaningful question is not how many claims the system denies. It is how many decisions survive complete, informed, human review.

10. A black-box score cannot substitute for an explanation

A provider, patient, regulator, or court should be able to understand why a claim was denied.

” The model determined that the claim was inconsistent with expected utilization” is not an explanation. It is a restatement of the conclusion.

A defensible denial should identify:

• The specific policy or rule applied
• The clinical or documentation fact considered missing
• The portion of the record reviewed
• The reasoning connecting the facts to the decision
• The identity and qualifications of the human reviewer, when required
• The steps necessary to correct or appeal the determination

Without that information, the provider is not meaningfully reviewing a denial. The provider is attempting to reverse an unexplained computer output.

The Accountability Imbalance Is Real

The practical legal and operational imbalance is difficult to ignore.

When an insurer uses AI to recommend or initiate an adverse coverage decision, the resulting harm may be treated as a utilization-management dispute, a contract issue, or an administrative appeal. The insurer may characterize the system as merely a decision-support tool. The patient and provider are then directed into an appeals process, often after care has been delayed.

Investigations have reported concerns regarding the use of algorithms by Medicare Advantage plans to limit or terminate care. Those concerns are especially serious because coverage-decision algorithms generally do not face the same regulatory framework as AI systems regulated by the Food and Drug Administration as medical devices.

That does not mean insurers are legally immune. They are not. State insurance regulators, the Centers for Medicare & Medicaid Services, contractual obligations, federal program requirements, and other legal mechanisms may apply. The National Association of Insurance Commissioners’ model guidance recognizes the need for governance, risk management, oversight, documentation, and accountability when insurers use artificial-intelligence systems.

But the immediate and visible risk often falls on the provider.

If a provider’s AI system invents a diagnosis, adds an unsupported modifier, creates a nonexistent medical-history fact, or generates documentation that does not accurately reflect the service provided, the provider may face:

• Claim denials and recoupments
• Prepayment review
• Post-payment audits
• Contractual sanctions
• Licensing or disciplinary consequences
• Civil penalties
• Exclusion concerns
• False Claims Act exposure
• Reputational damage

The use of AI does not transfer the provider’s compliance obligations to the software vendor. It does not make an inaccurate claim accurate. It does not convert an unsupported medical record into reliable documentation.

At the same time, an AI hallucination does not automatically establish fraud or a False Claims Act violation. The False Claims Act’s knowledge standard requires actual knowledge, deliberate ignorance, or reckless disregard, not mere negligence alone.31 U.S.C. § 3729(b)(1). Materiality and the circumstances surrounding submission also matter. Universal Health Services, Inc. v. Escobar, 579 U.S. 176, 181-92 (2016)

That distinction is critical. Providers should not be punished merely because a supervised tool makes an error. But providers that deploy AI without meaningful controls, fail to review its output, ignore repeated errors, or submit claims they have reason to know are inaccurate may create significant compliance risk.

The same principle should apply to insurers.

An insurer should not be permitted to hide behind a vendor when its automated system improperly denies medically necessary care. Medicare Advantage regulations, for example, restrict an organization’s ability to contract away civil liability for damage caused to an enrollee by the organization’s denial of medically necessary care.42 C.F.R. § 422.212. The entity that deploys the system must remain accountable for the system’s operation.

“The party that chooses the model, supplies the data, defines the objective, deploys the workflow, and benefits from the result cannot disclaim responsibility by pointing to the vendor.”

AI Requires Humans at the Front, Middle, and End

The proper healthcare model is not “AI replaces the professional.” It is:

Human judgment at the front. AI assistance in the middle. Human accountability at the end.

At the front: humans create the source material

The quality of an AI output depends on the quality of the input.

Clinicians must document what occurred, why it occurred, what was found, what was considered, and what was done. Staff must enter accurate patient and insurance information. Organizations must design workflows that preserve the integrity of the medical record.

AI cannot repair a fundamentally incomplete clinical encounter. It can identify a gap. It cannot truthfully fill that gap unless the provider supplies the underlying fact.

The front-end human responsibilities include:

• Accurate clinical documentation
• Complete histories and examinations
• Clear medical decision-making
• Proper identification of services
• Accurate patient and payer information
• Appropriate authorization procedures
• Clear communication with coding and billing personnel
• Protection of patient privacy and data security

In the middle: AI can accelerate professional work

This is where AI is most useful.

AI can assist with:

The middle of the process is not a license for automation without supervision. It is the place where trained professionals use technology to work more efficiently.

At the end: humans make the accountable decision

Before a claim is submitted, a professional must be able to answer:

• Does the documentation accurately describe the service?
• Does the code reflect the documented work?
• Is the modifier supported?
• Is the medical necessity rationale present?
• Does the claim comply with applicable payer and regulatory requirements?
• Did the AI invent, assume, or omit anything?
• Would the provider be prepared to defend the claim before an auditor, regulator, payer, or court?

If the answer to those questions is unknown, the claim is not ready.

The final human review is not ceremonial. It is the point at which an organization accepts responsibility for what it submits.

Why AI Will Not Replace Auditors, Billers, and Coders

AI will replace certain tasks. It will not replace the professions.

Auditors

An auditor does not merely find mismatches. An auditor evaluates evidence, understands process failure, tests controls, recognizes patterns, interviews personnel, distinguishes isolated error from systemic conduct, and explains findings in a manner that can withstand scrutiny.

AI can identify what deserves attention. It cannot independently determine the significance of every discrepancy.

The strongest auditors will use AI to expand their reach, not surrender their judgment.

Billers

Billing is not the mechanical act of transmitting a claim. It involves payer rules, authorization requirements, edits, timely filing, coordination of benefits, documentation, appeals, communication, and the practical realities of resolving disputes.

A skilled biller understands when a denial is legitimate, when it is technical, when it reflects a payer-processing error, and when the record requires clarification. That is not merely data entry. It is operational reasoning.

Coders

Coding requires disciplined interpretation. A coder must connect the record to the code set without adding facts that are not documented or overlooking facts that are.

The coder must understand that:

• A more specific code is not always a more accurate code
• A higher-paying code is not automatically supported
• A physician’s terminology may require clarification
• A modifier must reflect actual circumstances
• A diagnosis must be clinically and documentarily supported
• A code must be defensible after the claim is submitted

AI can propose. A coder must decide.

The Correct Standard: Augmentation, Not Abdication

Healthcare organizations should stop asking whether AI can eliminate people. The more responsible questions are:

• What task is AI performing?
• What data is it using?
• What can go wrong?
• Who reviews the output?
• How is the review documented?
• What happens when the AI is wrong?
• Can the decision be explained and challenged?
• Is the model being measured for accuracy, or merely for financial performance?

A responsible AI program should include:

• Pre-deployment validation
• Ongoing accuracy testing
• Bias and disparate-impact monitoring
• Version control
• Audit trails
• Defined escalation procedures
• Human override authority
• Periodic retrospective review
• Vendor accountability
• Data-security safeguards
• A process for correcting erroneous outputs before submission or adverse action

The NAIC’s model bulletin on insurers’ use of artificial-intelligence systems reflects the broader principle that AI deployment requires governance and accountability, not merely technical capability.

The same principle must govern providers.

Providers should never allow an AI system to:

• Create unsupported clinical facts
• Automatically sign documentation
• Select a final code without review
• Submit a claim solely because the model approved it
• Alter the medical record without traceability
• Generate medical necessity language disconnected from the actual encounter; or
• Conceal uncertainty behind confident wording

The responsible question is not whether AI sounds persuasive. It is whether the output is true.

The Future Belongs to Professionals Who Know How to Use AI

The future of healthcare revenue cycle management will not be human versus machine. It will be professionals who understand how to use AI versus organizations that blindly trust it.

The best billers will use AI to find claims that need attention faster. The best coders will use AI to identify potential documentation gaps while preserving independent coding judgment. The best auditors will use AI to analyze larger data sets while applying human skepticism to the results. The best compliance officers will require evidence that the technology works before allowing it to influence patient care or payment.

AI can help us process more information. It cannot bear moral responsibility. It cannot independently understand the patient. It cannot explain why a clinician made a difficult decision. It cannot replace the professional obligation to be accurate, fair, and defensible.

Human beings reason. We use logic. We evaluate context. We understand consequences. We apply process. We recognize that two records containing similar words may describe entirely different clinical realities.

We do not reduce every human judgment to a tokenized probability.

AI has a legitimate and necessary place in healthcare. But its proper role is to support professionals, not to replace them, conceal payer conduct, manufacture denials, or create a false appearance of certainty.

The 60 percent denial claim is not proof of intelligent adjudication. It is a reminder that the healthcare industry must demand better questions, better data, better oversight, and better accountability.

The future should not be automated healthcare without humans.

It should be better healthcare in which humans use automation responsibly.

That distinction is not academic. It is the difference between technology that improves the system and technology that merely makes bad decisions faster.

Contact Us

The post The AI Mirage in Healthcare Billing: Why Technology Will Not Replace Human Judgment appeared first on DoctorsManagement.

• Should athletes train their vision?
• What World Cup finalists teach us about talent
• The next heat management breakthrough?

Should athletes train their vision?

Earlier this month, human performance specialist Stijn Lintermans sparked widespread debate and discussion with a highly informative LinkedIn post on visual training. What makes the post particularly engaging is that Lintermans not only showcases videos of a range of visual training drills and exercises but also explains the proposed benefits of each.

In one clip, Celtic F.C. footballer Reo Hatate can be seen performing rapid left-to-right and up-and-down eye movements during his warm-up. Lintermans refers to this as “Saccadic training,” which is proposed to increase the speed and accuracy of visual scanning during games.

Recent Wimbledon champion Jannik Sinner is shown lying on his back, focusing on a tennis ball suspended from a string and hovering at varying heights above his face. According to Lintermans, this drill helps develop hand-eye coordination and depth perception. Women’s world number one Aryna Sabalenka is also featured throwing and catching a tennis ball with her coach while covering one eye with her hand. This exercise is proposed to improve timing, ball tracking, and anticipation.

The Italian national football team can also be seen training while blindfolded or with an eye patch over one eye. Lintermans explains that this encourages the brain to rely more heavily on timing and anticipation.

The video concludes with several elite athletes, including basketball legend Steph Curry and American football star Marvin Harrison Jr., juggling balls. Lintermans describes juggling as a fantastic way to activate the visual motor system before training or competition.

Lintermans finishes his post with an important reminder that athletes should not neglect training their brain, vision, and decision-making ability. If you are interested in this topic, please check out our courses Anticipation and Decision Making in Team Sports and our blog How tennis ball drills can help develop hand-eye coordination.

What World Cup finalists teach us about talent

I’m sure the vast majority of us tuned into the World Cup final between Spain and Argentina last week. Well, Dr Juan Delgado provided some fascinating insight in a social media post into the squads of both nations.

Interestingly, according to Delgado, the relative age effect still exists at this level, with players born earlier in the year remaining overrepresented at the elite level. Spain had 39% of their players born in the first quarter of the year compared to just 13% born in the fourth quarter. Meanwhile, Argentina had 35% born in the first quarter compared to 17% born in the fourth quarter. (Our relative age effect course can be found here).

Interestingly, Delgado outlines that across both squads, nearly one-quarter of the players were classed as late developers (22% early developers, 54% on-time developers, and 24% late developers). This further reinforces the importance of ensuring youth academies do not neglect or overlook late developers.

The post also shows that, on average, it took approximately three years after players made their professional debut before they reached international level, indicating that there is a substantial development period before becoming an international player.

This post by Delgado provides a fascinating insight into the journeys of elite footballers and further highlights the importance of long-term development and understanding maturation. As Delgado outlines in his infographic, “Late bloomers win big too.”

Earlier this year, I featured another of Delgado’s posts, which explored Rodri and Harry Kane’s inspiring journeys (see here). It is well worth checking out, especially considering both had excellent World Cups.

The next heat management breakthrough?

Sticking with the World Cup, there has been significant discussion around the Therabody CryoTherm Palm device. England’s players have been using the handheld device as part of their heat management strategy. Unlike traditional cooling methods that cool the entire body, this device specifically targets the palms of the hands.

The palms contain specialised blood vessels known as arteriovenous anastomoses (AVAs), which are among the body’s primary sites for heat exchange. These vessels allow heat to be transferred from circulating blood more efficiently than many other areas of the body. The theory behind the CryoTherm Palm is that cooling the blood as it flows through the hands can help lower core body temperature, reduce thermal strain, and ultimately delay fatigue.

Interestingly, some scientific research supports the effectiveness of this device. A study with elite footballers from IMG Academy found that athletes who used palm cooling reported feeling 60% cooler and maintained their sprint speed better compared to control conditions. Another study involving collegiate athletes showed that participants who used palm cooling between sets of the overhead press completed 58% more repetitions in their final set compared to the control group.

However, it is important to note that much of the current evidence comes from Therabody-funded research or studies conducted in collaboration with the company. While these findings are promising, they should be interpreted with caution until they are replicated by independent researchers.

As major sporting events continue to take place in increasingly hot environments, it will be interesting to see if palm cooling becomes a more widely adopted strategy for managing heat stress and helping athletes maintain their performance. If you want to learn about other heat management strategies the England team has been using, check out our previous edition of SFS Weekly here.

From us this week:

>> New course: Menstruation in Sport
>> New podcast: Frontal Plane Fundamentals with Dr Matthew Ibrahim
>> New infographic: Salivary Immunoglobulin
>> New article: Hydrotherapy

Access to a growing library of sports science courses

SFS Academy is an all-access membership to premium sports science education.

With SFS Academy, you’ll learn from some of the best coaches around the world as they teach you how to apply the latest research and practice with your athletes.

The post Sharper Vision, Better Performance? appeared first on Science for Sport.

Dr Kostas Karagiannopoulos tackles one of the hardest aesthetic challenges: matching a single central crown.

Matching a single central crown is probably the hardest task aesthetically for a restorative dentist. If you throw in the enigma of that crown being a replacement one, the restorative challenge becomes even greater.

This patient requested a crown replacemen. Patients usually do not know about the complexities involved and why would they even expect anything else other than perfection? Opacity, form, line angles, value, restorability and incisal effects simply do not even cross the patient’s mind. They want it to match the tooth next door which usually has its own eccentricities and defects. 

Assessment and consent

First things first! Consent and restorability assessment. Below are some key consent points:

• ‘I do not know what is under your crown’
• ‘X-rays and CBCT may help but do not exclude cracks or caries’
• ‘Nine out of 10 crowns I replace are fine for like-for-like renewal’
• ‘You need to be prepared for additional work: endo, post or even losing the tooth!’
• ‘I will need to remove your crown merely for the purpose of assessing the condition of the supporting tooth’
• ‘You will have an excellent temporary crown thereafter’
• ‘I may need a few attempts until I can match the final crown to your natural teeth’
• ‘If you want brighter teeth, we need to do whitening first and it will delay the outcome by six weeks.’

Step 1: Restorability assessment

We start this by considering the shape of the provisional the patient will leave with. If we can control the tooth shape intra-orally, we can take an index/stent of the existing/adjusted crown to use for the temp. Otherwise we may need a wax-up to mirror the contralateral crown tooth.

Step 2: Capture the data

This aims to gather all the information needed by the dental technician. We start with shade matching as dehydration affects value massively within a few minutes, hence it is best not to carry out this step during restorability assessment.

Finally IOS/imps of the prep, opposing teeth, a bite record and a copy of the provisional (ideally superimposed over prep model) should be taken.

It is the clinician’s responsibility to identify the base shade and give that to the technician. Other information the lab requires include:

• Zirconia or Lithium based
• Degree of translucency (HT, MT, LT)
• Degree of texture (low, moderate, high)
• Degree of lustre (high or satin gloss)
• Incisal effects (mild, moderate, high)
• Tooth map drawing to describe specific things needed eg opacities, CEJ, line angles etc.

It is also an option to send the patient to the lab for a custom shade match and even a custom finish on the day of cementation.

Pricing for a single crown must allow for the above as well as multiple try-ins potentially. A single anterior crown should be priced at 50-100% more than the fee of a standard crown.

Step 3: Cement the crown

In this case, the crown was made using LiSi PRESS (GC) with facial layering.

A try-in paste is recommended to check colour match under different lights and allow adequate time for the patient to verify and approve. A few attempts/returns may be needed with the relevant photos to convey the message to the lab for changes needed. Once all parties are satisfied, use resin cement and isolation as per clinician’s choice. In this case G-CEM ONE (GC) A2 resin cement was used under rubber dam isolation.

The final result

This article is sponsored by GC.

With the full conference programme now live, Dentistry Show London (DSL) 2026 is giving dental professionals the chance to plan two days of education, innovation and networking tailored to the challenges facing modern practice.

Taking place at ExceL London on 9-10 October 2026, the free-to-attend event will welcome more than 4,000 dental professionals for a programme designed to help practices stay ahead in an increasingly fast-moving profession.

Following the success of the British Dental Conference & Dentistry Show (BDCDS), which welcomed more than 10,300 delegates to Birmingham earlier this year, Dentistry Show London returns with a focused programme that brings together leading clinicians, business experts and industry innovators to explore the issues shaping dentistry today and tomorrow.

Education that reflects the realities of practice

Today’s dental professionals face a rapidly evolving landscape. From NHS reform and advances in artificial intelligence to changing patient expectations and new clinical evidence, keeping up to date has never been more important.

With more than 100 expert speakers across six CPD-accredited theatres, Dentistry Show London has been designed to provide practical insights that delegates can take straight back into practice.

One of the most anticipated sessions will see chief dental officer for England, Jason Wong, reflect on the impact of NHS contract reform in ‘Six months since the contract reform: what has changed and what’s next for the future of oral health’, offering valuable perspective on where the profession is heading.

The growing connection between oral and systemic health will also take centre stage as Dr Victoria Sampson explores the latest evidence linking oral health with wider health outcomes and what this means for patient care.

For practices looking to embrace new technologies, Lisa Bainham will demonstrate how AI and automation can transform every stage of the patient journey – from the first enquiry through to ongoing communication – helping teams improve efficiency while enhancing the patient experience.

Clinical updates remain a cornerstone of the programme, including Professor Martin H Thornhill’s session on the latest guidance surrounding infective endocarditis prevention, ensuring delegates stay informed about important changes affecting day-to-day clinical decision making.

The programme also recognises the increasing diversification of modern dental practice. In ‘Six months roadmap: introducing medical aesthetics into your dental practice’, Bethany Rossington will share practical advice for teams considering expanding their services, while Jaz Gulati will explore how professionals can build rewarding and sustainable careers beyond purely clinical dentistry.

Alongside these headline sessions, delegates can choose from a wide range of lectures covering restorative dentistry, endodontics, orthodontics, clinical photography, patient anxiety management, career development, digital workflows and much more.

More than a conference

While the education programme is central to the event, Dentistry Show London also provides opportunities to discover the latest innovations transforming dentistry.

More than 180 exhibitors will showcase new products, technologies and services across the exhibition floor, giving delegates the opportunity to compare solutions, watch demonstrations and speak directly with manufacturers and suppliers.

Whether you’re exploring digital workflows, looking for new equipment, considering practice management software or simply wanting to understand what’s new on the market, the exhibition offers a practical way to evaluate the latest developments in one place.

Networking is another key reason many professionals return year after year. Bringing together dentists, hygienists, therapists, dental nurses, technicians, practice managers and owners, the event provides valuable opportunities to exchange ideas, discuss shared challenges and build professional relationships across the wider dental community.

Plan your visit now

With the full conference programme now available, delegates can begin planning their visit in advance, selecting the sessions that best match their clinical interests, career ambitions and practice priorities.

Commenting on the programme, Océane Amoa-Thompson, senior content producer, said: ‘Whether delegates are looking to streamline workflows, strengthen team culture, improve patient communication or better understand the role of emerging technologies, Dentistry Show London offers a comprehensive programme designed to help practices grow, adapt and thrive.’

From practical clinical education and business insight to emerging technologies and valuable networking opportunities, Dentistry Show London 2026 promises two days dedicated to helping the profession move forward.

Dentistry Show London 2026 takes place at ExceL London on Friday 9 and Saturday 10 October 2026. Registration is free for dental professionals. To view the full conference programme and secure your place, visit london.dentistryshow.co.uk.

This article is sponsored by Closerstill.

Colgate explains the clinical evidence which sets Duraphat Fluoride Varnish apart from other varnishes for caries control in dental treatment.

Dental teams are presented with a wide range of professional products to support caries prevention including fluoride varnish. It is vital to understand that not all fluoride varnishes are the same. Although they may have similar compositions, they are intended for a different use. This difference can be clearly identified by their regulatory status as defined by the Medicines and Healthcare products Regulatory Agency (MHRA). The MHRA states:

• A medicine is any substance or combination of substances presented as having properties for treating or preventing disease in human beings (MHRA, 2021)
• A medical device’s principal mode of action does not include treating or preventing disease (MHRA, 2021).

Colgate Duraphat Fluoride Varnish is the only fluoride varnish with the legal status of a medicine, indicated for caries control. All other fluoride varnishes currently on the UK market are medical devices, providing treatment of hypersensitive teeth only. Although some may also suggest an implied caries benefit, this is not their intended purpose or mode of action.

As a medical device, their primary mechanism is to act by physical or mechanical means (MHRA, 2021). Medicines, on the other hand, act through pharmacological (as is the case with Colgate Duraphat Fluoride Varnish, licensed to deliver caries control), metabolic, or immunological effects (MHRA, 2021).

Why does this matter?

Delivering better oral health guidance recommends twice-yearly application of 22,600ppm fluoride varnish for all children aged three years and above for caries prevention. This increases to three-monthly applications for those at increased caries risk. For adults at increased caries risk, it may be a three- or six-monthly application, dependent on their caries pathway (OHID, 2020; DHSC, 2025).

To be clinically effective, a fluoride varnish delivering caries control should release free fluoride ions to both promote remineralisation and inhibit demineralisation during any drop in pH for six months following application (Seppa, 1984; Marinho et al, 2013). For this reason, the evidence base also states to use a fluoride varnish licensed for caries control (MHRA, 2021).

Colgate Duraphat Fluoride Varnish is the only licensed product available. Using a fluoride varnish licensed for caries control also meets dental practitioners’ responsibilities as a prescriber (NHS, 2009; NHS England, 2016). This point is also important for appropriately trained extended duties dental nurses (EDDNs) and for dental hygienists and dental therapists working to exemptions (NHS, 2009; NHS England, 2016; NHS England, 2025).

Transparent information

Unlike other fluoride varnishes, which are all medical devices, the Colgate Duraphat Fluoride Varnish product licence information is publicly accessible via the MHRA website (MHRA, 2026). This includes the Summary of Product Characteristics (SPC), which lists everything you need to know to make a considered choice prior to application. It includes the product indication, which is:

‘For the prevention of caries in children and adults as part of a comprehensive control programme

• For the prevention of recurring (or marginal) caries
• Prevention of progression of caries
• Prevention of decalcification around orthodontic appliances
• Prevention of pit and fissure (occlusal) caries.’

This prescribing information can also be found in an abridged format on all marketing materials for Colgate Duraphat Fluoride Varnish.   

Application

Prior to applying the Colgate Duraphat fluoride varnish, advise the patient, parent or carer on the purpose, benefits, process, possible side effects and alternatives to fluoride varnish (SDCEP, 2025). Ensure the patient has eaten prior to the application and let them know that the fluoride varnish is applied using a small brush and that it is quick, simple and painless. Let your patients know Colgate Duraphat Fluoride Varnish has a pleasant raspberry taste and fruity smell (NHS Scotland, 2025).

It is also useful to understand that the opaque yellowish tint found in Colgate Duraphat Fluoride Varnish is only temporary. It will wear off or can be brushed off four hours after application if desired. This tint acts as a useful guide that may be helpful when applying to a fidgety child.

Other fluoride varnishes (not licensed for caries control) can offer a range of flavours intended to engage children. This may cause confusion by implying the product could be used for caries control in children.

The evidence

A paper on the use of flavoured fluoride varnishes was recently reviewed, suggesting that flavour is not an effective way to engage a child (Cunningham et al, 2025). The review suggested a better way of engaging a child would be to offer them a choice of safety glasses or ask them which side of the arch they would like to start on to offer the child an element of control. More importantly, the child would be receiving Colgate Duraphat Fluoride Varnish, clinically proven to release fluoride ions to both promote remineralisation and inhibit demineralisation during any drop in pH within a six-month period (Seppa, 1984).

It is increasingly important to consider fluoride varnish application for adults at higher caries risk. This includes the planned caries pathways for higher risk adults put forward as part of the proposed dental reform, aligning with the 10-year NHS plan (NHS England, 2025).

Protect your patients, your team and your dental practitioners’ responsibilities with Colgate Duraphat Fluoride Varnish.

Click here for more information on Colgate Duraphat Fluoride Varnish.  

*Colgate Duraphat fluoride varnish for patients three years of age and over.

References

1. https://www.gov.uk/guidance/borderline-products-how-to-tell-if-your-product-is-a-medicine
2. https://www.gov.uk/guidance/borderline-products-how-to-tell-if-your-product-is-a-medical-device
3. Delivering better oral health – an evidence-based toolkit for prevention, Office for Health Improvement and Disparities’ 2021. Oral Health Survey of Adults attending dental practices, 2018. Public Health England, published 2020
4. Dental contract quality and payment reforms, DHSC Consultation Webinar, Tuesday 15 July 2025
5. Seppa L (1984) Fluoride content of enamel during treatment and 2 years after discontinuation of treatment with fluoride varnishes. Caries Res 18: 278-281
6. Marinho VCC, Worthington HV, Walsh T, Clarkson JE (2013) Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews
7. The use of fluoride varnish by dental nurses to control caries. NHS. Primary Care Commissioning, 2009
8. Avoidance of Doubt – Application of Fluoride Varnish by Dental Nurses. Chief Dental Officer, NHS England. 2016 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/09/avoidance-doubt-v4-1.pdf
9. Supply and administration of medicines by dental hygienists and dental therapists, NHS England. 2025. https://www.england.nhs.uk/long-read/supply-and-administration-of-medicines-by-dental-hygienists-and-dental-therapists/
10. https://products.mhra.gov.uk/
11. Professionally-delivered interventions in caries prevention, SDCEP. 2025. https://www.childcaries.sdcep.org.uk/guidance/caries-prevention/professionally-delivered-interventions/
12. Fluoride varnishing, Childsmile, NHS Scotland. 2025. https://www.childsmile.nhs.scot/parents-carers/fluoride-varnishing/
13. Cunningham B, Linden J (2025) Using flavour in your favour: does giving children an element of control help them engage more positively with the dental experience? Evid Based Dent 26: 97-98 https://doi.org/10.1038/s41432-025-01162-3
14. ‘Fit for the Future’ 10 Year Health Plan for England. NHS England. 2025.

This article is sponsored by Colgate.

Burnout does not always arrive as a dramatic collapse. Sometimes it looks like another full diary, another yes, another day of telling yourself you will rest when things calm down in the surgery.

Lynn Blades knows this pattern well. The founder of Legacy Leadership, journalist and author of The Quiet Burn, she has spent years helping high-performing professionals recognise what they have been trained to ignore.

In this episode of Dentistry Talks, Blades explores why so many professionals miss the warning signs until their body forces them to stop and why dentistry, with its clinical precision, patient expectations, perfectionism, complaints risk, business ownership and the emotional labour of caring for people who are already anxious in the chair, is particularly exposed.

‘The dental industry is full of pressure,’ she says.

Blades argues that one of the biggest myths about burnout is that it can be fixed over a long weekend. The real question, she says, is whether you are recovering properly.

Warning signs include continuous fatigue, brain fog, forgetfulness, loss of interest in things that usually bring joy, physical pain, appetite changes, withdrawal and waking up without feeling rested.

‘When you get to the point where I cannot get out of bed, that is too late,’ she says. ‘That means you have not paid attention.’

How to identify burnout

The episode also looks at how practice leaders can spot burnout in colleagues. Blades says changes in behaviour, more sickness absence, withdrawal, loss of confidence or taking on too much can all be signs that someone is struggling.

Her advice is direct: ask what is going on before the person breaks.

A major theme is boundaries, particularly the difficulty many people have with saying no.

‘No is a beautiful word,’ Blades says. ‘No means self-respect, no means boundaries.’

She argues that people who always say yes can become the ‘worker bee’ who gets everything done without the recognition, promotion or space to shine.

Blades also shares her own burnout story, including the back pain she ignored until two discs collapsed and she needed surgery. It was, she says, the hard way to learn that she was not superwoman.

You can now watch on YouTube and listen on Spotify.

Topics include:

• The early warning signs of burnout in dentistry
• Why recovery matters more than stress alone
• How to spot burnout in colleagues
• Saying no, boundaries and people pleasing
• Social media comparison and professional pressure
• Why self-care is a leadership skill.

Listen to other episodes below:

• How an Olympic bobsleigh athlete learned to weather the storm
• Burnout, balance and building a brand: lessons from the Singing Dentist
• Ageing as a dental professional: how to maintain purpose and identity
• What every dentist needs to understand about trauma and dental anxiety 
• From pitchside to practice: lessons from sports dentistry.

Dentistry Talks podcast is powered by Sensodyne.

You can find out more here.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.

Raman Aulakh explains why every delegate is interviewed for the SAFE Clear Aligner Diploma and what the interviewers are looking for.

In dentistry, we would never begin treatment without first understanding the patient.

We listen, we assess, we diagnose. We explore what they want, what they understand, what they expect and whether the proposed treatment is genuinely appropriate for them.

Education should be no different.

That is why every potential delegate for the SAFE Clear Aligner Diploma is interviewed before joining. It is not a sales process. It is the first step in an educational relationship and often, the beginning of a mentor-mentee journey. To learn more about the Diploma, simply book an enrolment call at a time that suits you with one of our course directors, Dr Raman Aulakh or Dr Andy Toy.

Clear aligner therapy is not something a dentist ‘adds’ to their current practice. It requires diagnosis, judgement, communication, case selection, biomechanical understanding and the confidence to know when to proceed, when to pause, and when to ask for support. For that reason, choosing the right course matters. But so does choosing the right delegates.

The first thing to understand is the delegate’s ‘why‘

Adult learners do not arrive as blank pages. They bring experience, habits, anxieties, previous successes, and sometimes, difficult cases that have shaped how they now approach orthodontic treatment. One dentist may want to feel more confident reviewing a ClinCheck. Another may want to understand aligner biomechanics more deeply. Another may be looking to integrate orthodontics into wider restorative and aesthetic planning.

The interview helps us understand that motivation.

This matters because adult learning theory tells us that mature learners engage more deeply when education connects with their own experience, goals, and clinical reality. In other words, dentists learn best when they can see why the learning matters and how it will change what they do on Monday morning.

We are not looking for perfect answers. We are listening for purpose.

Those are very different starting points.

The second reason for interviewing is to protect the learning environment

A strong postgraduate programme is built by the faculty and by the people in the room.

The SAFE Diploma is interactive. Delegates discuss cases, challenge ideas, share experiences and learn from one another. That only works if the group is engaged. We want delegates who will contribute, not simply consume. We want clinicians who are prepared to ask questions, show cases, reflect honestly, and support their peers.

This idea is well recognised in education through the concept of communities of practice: groups of professionals who learn and improve through shared activity, discussion, and reflection. In clear aligner therapy, this is particularly important. Many of the most valuable learning moments come not from polished cases, but from honest conversations about what did not track, what was missed, or what could have been planned differently. The WhatsApp group the delegates belong to becomes a formidable resource and support system.

For that to happen, delegates need to feel safe.

Psychological safety is essential in clinical education. Dentists will not ask questions if they fear embarrassment. They will not share uncertainty if they feel judged. Yet uncertainty is often where real learning begins.

Understanding culture

The interview gives an early opportunity to explain the culture of the diploma. It is rigorous, but supportive. Evidence-based, but practical. Challenging, but human. We expect delegates to think, engage, and reflect, but we also make it clear that they are not expected to know everything before they arrive.

That is the point of education.

The interview also allows us to manage expectations honestly. The SAFE Clear Aligner Diploma is not a weekend course, a collection of tips and tricks, or a shortcut to confidence. It is designed to develop clinical thinking. It includes structured teaching, case discussion, mentoring, assessment, and support. Delegates need to know what the programme involves and what level of commitment it requires.

This is important because good education depends on alignment. The learner’s goals, the course outcomes, the teaching methods, and the assessment process all need to point in the same direction. When expectations are clear from the beginning, the learning experience is stronger.

Finally, the interview begins the mentoring relationship

Mentoring should not be considered only for answering clinical questions. It is a developmental relationship built on trust, honesty, and continuity. A mentor helps a clinician grow in judgement, not just knowledge. That cannot begin with a login code or a set of modules. It begins with a conversation.

• Where are you now?
• Where do you want to be?
• What cases are you treating?
• Where do you feel exposed?
• What would confidence look like for you?

Those questions help us understand how best to support each delegate. The diploma is not a box-ticking exercise. We are honest about readiness because we only want dentists to enrol if we know they will thrive.

Ultimately, this is about patient care. Clear aligner therapy is more accessible than ever, but accessibility must not be confused with simplicity. Dentists need to assess comprehensively, plan biologically, communicate ethically and understand their limitations.

The SAFE approach places clear aligners within comprehensive dentistry. It is about structure, aesthetics, function, and biology, and about helping dentists make better decisions for their patients.

That is why we interview every potential delegate.

Because the right conversation at the beginning helps create the right learner, the right cohort, and the right educational relationship.

And in the end, better education leads to better dentistry.

References

1. Aulakh R. Making an IMPACTT: A framework for developing a dentist’s ability to provide comprehensive dental care. BDJ In Practice. 2022.
2. Mukhalalati BA, Taylor A. Adult learning theories in context: a quick guide for healthcare professional educators. Journal of Medical Education and Curricular Development. 2019.
3. Wenger E. Communities of practice and social learning systems.
4. Biggs J. Constructive alignment in university teaching. HERDSA Review of Higher Education. 2014.
5. Hill SEM, Ward WL, Seay A, Buzenski J. The nature and evolution of the mentoring relationship in academic health centers. Journal of Clinical Psychology in Medical Settings. 2022.

This article is sponsored by Aligner Dental Academy.

Muhalab Al Sammarraie, D.D.S., is a site dental director at AltaMed Health Services, the nation’s largest federally qualified health center. A fellow of the International College of Dentists and graduate of the ADA Leadership Institutes, he was named a 2023 ADA 10 Under 10 Award recipient and an Incisal Edge magazine 40 Under 40 Top Dentist. He serves as a delegate for both the American Dental Association and California Dental Association, an international lecturer at Universidad De La Salle Bajio, and a preceptor for Tufts University School of Dental Medicine students.

Earlier this year, I stood in front of a room of dental students in their second year, only weeks away from the day a real patient would sit in their chair for the first time. I had been invited to talk about emotional intelligence in dentistry. I chose to begin somewhere less comfortable: what they were afraid of.

Early in a career, you are afraid — afraid your hands will shake, afraid you will hurt someone, afraid everyone will see and, underneath all of it, afraid you are not good enough to be there. The room changed. I was no longer describing a hypothetical. I was saying out loud the thing no one in the room had said yet.

Fear is not weakness. Every clinician I admire carried some version of it into the operatory. I did and so did the doctors those students will spend their careers admiring. The mistake is not being afraid. The mistake is hiding it and letting it harden into a wall.

So I asked them to do the opposite. Name it. Study it. Say it plainly. The fear you name becomes information while the fear you hide becomes a wall. Then I asked the question I care about more than any technique I could teach. Take two dentists: same school, same training, the same diploma on the wall. Why, 10 years later, are their careers, and the kind of doctors they have become, completely different?

It is not the degree because they hold the same one. Most of the time, it is not even the skill. The difference lives somewhere quieter, in what I have come to think of as a clinician’s internal architecture: the self-awareness, the mindset and the core values that quietly govern how we practice when no one is grading us.

Your skills tell the world what you are capable of while your internal architecture decides what you will do with that capability and who you become while doing it. We spend years in training, and training is good. It teaches diagnosis, technique, materials and judgment, but training and formation are not the same thing. Training builds the skill while formation builds the person.

The longer I practice, the more convinced I become that the only part of a professional life that is truly ours is the interior we build. Skills evolve, and techniques change. Titles come and go. But the person making the decisions behind all of them remains, and eventually, it is the person, not the skill, who decides how the skill gets used.

We measure the first constantly and the second almost never. Yet formation is usually what separates two clinicians who began in the same place and arrived somewhere completely different. Every procedure passes through the person performing it. Dentistry is not only the application of skill; it is the application of self.

I learned what that really means a few years ago, at the height of the pandemic, and I did not learn it from a moment I am proud of. We were working under strict time limits, and I had been in a respirator all day, the kind that leaves marks on your face by noon. A patient arrived, and there was a significant language barrier. Even with an interpreter on the line, I could not understand what she needed.

I want to be precise about what happened next because the easy version of this story is not the true one. The true version is smaller, and more uncomfortable.

I did not lose my temper. I did nothing a chart would ever record. I simply became efficient. I decided, somewhere beneath conscious thought, that this patient was taking longer than the day allowed. I told her, in so many words, that I did not understand what she wanted. And I left the room.

Nothing about that felt like a failure in the moment. That is the part worth sitting with. It felt like coping. It felt like keeping up.

That is how it actually works. No one decides, on a Tuesday, to become a smaller version of themselves. The pressure never asks for the whole thing at once. It asks you to see a little less, to move a little faster, to treat the chart and not the person, just this once, just today. Conscience does not collapse. It narrows, quietly, by degrees. And the respirator marks and the clock and the backlog were all, very politely, asking me to narrow.

I walked into the next operatory and began greeting the next patient. Then I stopped. Something in me said, “Go back.”

I have thought a great deal about where that voice came from because it did not come from my training. No course taught it. No board examined it. It came from the only part of me the diploma never touched. It was not empathy arriving out of nowhere. It was the interior catching the drift before the drift became who I was.

I excused myself and walked out to the lobby, which I almost never do. The first person I saw was her. She turned, and we made eye contact. I apologized. She broke down, hugged me and cried. Then she told me why.

Her oldest son was dying overseas. She could not travel and would not get to say goodbye. She had not come in that day for a denture. She had come in needing to be seen, to be heard, to be felt by another human being who was paying attention.

Here is what I understood, standing in that lobby. I had the clinical skill to help her the entire time. The skill was never in question. What the day had been quietly taking from me was not a skill at all. It was the willingness to stay present when everything in the room was rewarding me for moving on, and I had almost let it go.

The dentist who walked out of that operatory was the same dentist I had just described to a room of students. He was afraid — afraid of the language he could not speak, afraid of falling behind, afraid, underneath all of it, of not being enough for a day that was asking too much. I had not named any of it, so it did what unnamed fear always does. It hardened into a wall, a real one this time: the door I had closed behind me.

The fear I hid that day almost cost a grieving mother the one thing she came for. The fear I might have named would have been information. It would have told me to slow down, not speed up.

What kind of doctor are you becoming?

I said those words to a room of students, but somewhere in the middle of saying them, I understood the question was never really theirs. It belongs to the new graduate and the practice owner. To the educator and the clinician approaching retirement. It belonged to me, on a Tuesday, in a respirator, at the worst moment of a long day. And here is the part I would ask every young dentist to hold onto: The answer to that question was not in the scene where she cried. That is the scene everyone remembers, but it is not the scene that decided the kind of doctor I was. The answer came three seconds earlier, in an empty hallway, when no one was watching and no one was grading me, and I turned around.

That turn is not taught. It is built quietly, over years, in the choices no patient ever sees, until one day it is strong enough to turn you around when the entire system is pushing you forward. Your patients will never see your internal architecture. They will only ever live inside the decisions it makes.

So build it on purpose. The diploma decided what you are capable of. Formation decides what you will do with it, and who you will be in the three seconds when it is only you, the hallway and the choice to go back.

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