A reader wrote:

Larry: The other day a 17-year-old patient came into my office. He had been in braces with his general dentist for almost 2 years. He is still Class II on 1 side and needs all new appliances, about 18 to 24 months more of care, and the extraction of 1 premolar. Here’s the problem: the GP in question is my second best referral source. She said that if I take over the case she will agree to debond it and clean it up. She has been fully paid, and the patient’s insurance has been used up. The GP wants me to bill her for whatever my fee is to finish the case. I still have to take full records but from the initial clinical examination and Panorex, the roots look good, as do the hard and soft supporting tissues, and the case is doable. On top of all this, her practice is within 3 miles of mine, and this will be the second case from her that I will have taken over to finish or redo. Here are my questions.

How much should I charge the GP? What do I need to get in writing from both the parent and the GP (and how do I ask for it) to not be responsible for whatever treatment the GP has rendered up to this point? If the GP gets sued over this, am I involved and responsible for anything? What forms or letters do I need to complete or have signed?

Although the fact pattern here may seem extreme in some respects, it is quite real, and it happens more often than we would like. Most of the time the transfer comes from another orthodontist, but regardless of the source, the scenario is almost always as follows. The patient has been in treatment for a given length of time; the patient has often been told that he or she is almost completed, when that is not the case. The appliances in place are not ones we would prefer to use; unfortunately, the patient often has pathology in the form of periodontal compromise, various degrees of decalcification or caries, or some root resorption. Finally, to add insult to injury, the case has been paid up with no insurance left. Is it any wonder that many practitioners don’t accept transfer patients?

In our scenario, the transferee seems lucky. The first doctor will strip and clean up the teeth and is willing to pay for the retreatment. How much is the question, and for that there is no simple answer. From a practice management perspective, you could just treat it like any other case. After you take your records and present the treatment plan, just quote the referring doctor what your normal fee would be. Alternatively, I think I would tell the patient that insofar as transfers like this are concerned, you have an arrangement with the referring doctor, and the fee will not be a concern to the patient. This posture could alleviate many, but not all, potential problems between you and the patient, and between the patient and the previous practitioner.

Another approach might be to extend whatever professional courtesy you would to any referring dentist as if you were treating a member of his or her family.

Although it is certainly ethical (beneficence, justice, professional collegiality, public fiduciary, and so on), it may present some administrative concerns regarding the usual and customary fees being charged, but one could always argue that this is not a usual and customary situation. Regardless, there is no good answer, and the effort should be directed at making the patient as financially comfortable as possible while recognizing and addressing the business concerns of keeping a good referring dentist happy.

Whereas the first question has as its basis practice management considerations, the second deals more with risk management considerations. What special documentation must be acquired to protect oneself from any liability that may be attached to the first doctor’s treatment? The answer is simple: none. You are not liable for anything the first doctor said or did before you accepted the patient. You are, however, responsible for everything going forward. A basic tenet of tort law is that you take your potential plaintiff as you find him. Look at it this way: if a new patient came to your office with a periodontal status that was not compatible with the initiation of orthodontic therapy, you would refer him for treatment until the periodontal status was under control. If the patient had gross caries, you would have them restored before beginning treatment. If the patient had abnormal root morphology, blunted or shortened teeth, or something else, you would develop a treatment plan compatible with his anatomic and physiologic limitations, and the same for edentulous areas with knife-edge ridges. The bottom line is that you take every patient—and every patient is a potential plaintiff—as you find him, and you deal with it accordingly. Would you refuse to treat these patients? Most doctors I know possess professional egos big enough to surmount whatever potential pitfalls loom on the horizon. Well, it’s the same thing with transfer patients. Whatever you find, you diagnose it, plan the treatment, get your informed consent, and you’re off.

If everything is good, and our fact pattern shows that it is (periodontium, root integrity, and so on), then you will treat this patient as you would any Class II subdivision patient, and you will only be responsible for your diagnosis, your recommended treatment plan, and the treatment you render. From a purely clinical perspective, it doesn’t matter why the patient came to you, except for possibly a history of poor cooperation. What does matter is how you choose to play the cards you are dealt.

To minimize your risk exposure, you want to have good beginning records to document exactly how the patient presented—records that will support whatever you choose to do. You want to have good documentation about the treatment plan presented based on the clinical considerations. You want to have good documentation of the patient’s informed consent to the treatment proposed and the patient’s responsibilities going forward. The previous doctor’s problems, whatever they were, are not yours, and you don’t want to make them yours. This is your patient going forward, pure and simple. Just use all the normal forms and letters as you would for every other patient presenting as this patient does. You are taking and treating your new patient as you find him.

This obviously leads to the next question. If the previous dentist gets sued, will you be involved or responsible for anything? Well, you won’t get sued, but you will surely be invited to the party. You will most assuredly be called as a treating physician, a fact witness, who will be asked to testify about the patient’s status when you first saw him, the way the first doctor left him. You will be asked about all aspects of the patient’s presentation, what your treatment plan was, and whether the previous doctor’s treatment affected the treatment you rendered to the patient. The patient’s attorney will try to get you to be an expert witness for the patient, but the defendant’s attorney will try to block that and keep your testimony strictly to the facts. It will make for an interesting day in court for which you will probably not get paid, because you have been subpoenaed to appear. Ain’t life grand?