A dentist can explain every risk and benefit of a proposed treatment and still miss a key part of informed consent: what the procedure will cost.
Dentists should ensure that their patients receive and understand the cost information that matters to their decisions. They should also record that discussion in the patient’s file. A signed consent form with no cost information is not enough. Neither is an insurance predetermination, a discussion with administrative staff, or a patient’s general willingness to go ahead. None of these may prove that informed consent was given.
Clear conversations about costs help patients make informed decisions and help dentists avoid regulatory issues.
A patient doesn’t have to say ‘cost matters’ for it to matter.
The anticipated cost of treatment can be an important part of informed consent. How much it matters depends on the circumstances, including the amount, whether the patient has indicated that cost or insurance coverage could affect their decision, and whether the patient has asked for information about insurance coverage or pricing.
Money matters to every patient but questions about fees, insurance limits, predeterminations, or out-of-pocket costs cancan signal that it is an especially important consideration for a particular patient. Repeated questions about cost or coverage can reinforce that. When that happens, dentists should give clear information before treatment starts.
Patients do not have to expressly say that affordability will determine their decision. If the cost of treatment is substantial, the dentist should help the patient understand that.
Sending a predetermination doesn’t mean the patient understood it.
An insurance predetermination can provide useful information about anticipated coverage for a patient, but submitting one does not establish that the patient received or understood that information. Further, it does not replace a cost discussion.
A patient’s general willingness to proceed with treatment does not prove they understood the expected treatment fee, how much insurance is expected to cover, or how much the patient may have to pay out of pocket, including the chance that insurance pays less than expected.
Before treatment begins, the dentist should make sure the patient understands the expected or estimated costs alongside any cost uncertainties.
A dentist can hand off the paperwork, but not the responsibility.
Administrative staff can assist with estimates, insurance claims, predeterminations, and talks about money. Handing off these tasks, however, does not remove the dentist’s duty to make sure that the patient gave informed consent after they have understood the costs of the procedure.
The dentist does not have to personally conduct every administrative discussion, but the practice should have a reliable process for communicating treatment costs with patients and passing along unanswered questions. The dentist should not proceed where there is reason to believe that the patient may not understand the cost or where important money questions remain unanswered.
Treatment plans are written in pencil, not ink.
Dentists should also explain, and document, that a treatment plan may change as treatment goes on. A plan may seem final when it is made, but it can change as treatment progresses.
For example, a tooth with a deep cavity may not respond to the first treatment and may need a root canal. New test results, changes in the patient’s health, or changes in the patient’s money or personal situation can also mean the plan needs to be reconsidered. A patient may also decide to delay or decline treatment they had agreed to earlier.
Dentists should therefore prepare patients up front for changes that could reasonably happen, including what those changes could mean for their health and their wallet.
Still, not every change needs a whole new consent process. According to the RCDSO, unless it would be unreasonable, a dentist may assume consent covers:
Small changes to the treatment, where the type of treatment, expected benefits, and material risks and side effects of the changed treatment are not significantly different; and
Continuing the same treatment in a different setting, where the new setting does not significantly change the expected benefits, risks, or side effects.[1]
This exception is important, but narrow. It is not permission to go ahead with substantially different treatment without talking to the patient first. If a change significantly affects the type of treatment, its benefits, risks, side effects, or cost, the dentist should discuss it with the patient and obtain and document the patient’s consent before proceeding.
If it isn’t in the chart, it’s hard to prove it was ever said.
Good records are essential. Without them, it may be difficult to establish what financial information the patient received or understood before consenting to treatment.
Dental practices should consider documenting:
The expected treatment fee;
Any written estimate given to the patient;
How much insurance is expected to cover;
How much the patient may have to pay;
Any doubt about the final cost or insurance payment;
The patient’s questions about cost or coverage;
The answers given, and by whom;
Changes that could reasonably happen to the plan or cost; and
The patient’s decision after getting this information.
If the treatment plan changes significantly, the record should also show why it changed, the new clinical and cost information shared with the patient, and the patient’s decision.
A record should show more than a signed consent form. It should show that the patient received the information that matters to their decision and had an opportunity to ask questions before treatment began.
A signed form shows a patient said yes. It doesn’t show they knew what they were saying yes to.
Informed consent is not established merely because a patient signs a form or indicates a willingness to proceed. Where treatment has significant financial implications, dentists should ensure that anticipated fees are clearly explained and understood, record the discussion, and retain oversight even where administrative staff assist with financial matters.
Dentists should also prepare patients for reasonably foreseeable changes to the treatment plan. Consent may extend to minor adjustments. Material changes, including changes to cost, should be discussed and documented before treatment continues.
The key takeaway:
Talking about cost during consent discussions, and documenting those discussions, is part of good patient care. If a dentist skips it, the consent may not hold up, and the dentist could face regulatory action.
1. RCDSO, Frequently Asked Questions – Consent to Treatment: What happens if the patient’s treatment plan changes unexpectedly after consent has been obtained?
