Good Concepts to Follow When Referring to Specialists – Avoiding Personal Liability and Vicarious Liability

Good Concepts to Follow When Referring to Specialists – Avoiding Personal Liability and Vicarious Liability

Having a process for when and how to refer patients for complicated cases can help protect your dental practice from potential litigation. Here are some tips for building out a trusted network of specialists and avoiding vicarious liability risks.

By Dr. Ty Galvin, D.D.S., and Dr. Mike Gile, D.D.S.

There is a fine line between when to refer to a specialist for a complicated procedure and when to perform the work yourself. Knowing your strengths and limitations — and those of your network of specialists — can help ensure that you make the best decision for your patients and your practice.

Consider the case of the dentist who worked on a patient’s implants for a bone density issue. The dentist used the wrong size implants, they didn’t integrate properly, and they were not solid in the bone. After the dentist spent more than a year trying to get them fixed and adjusted, the patient still had to have them removed and redone by another provider, which led to an $80,000 claim against the first dentist.

While the dentist in the above case should have referred the patient to a specialist familiar with bone density issues, referring a patient to a specialist’s office for a procedure or condition can also bring risks for the referring dentist. The greatest of those risks is a vicarious liability claim against the general dentist if something goes wrong with the specialist’s treatment. For this reason and more, it is important to select your specialists carefully.

The true costs of a vicarious liability lawsuit — or any other for that matter — lie in the often long and invasive litigation process. It can involve getting publicly served with the lawsuit at work and having documents from discovery available online that detail income, past lawsuit history, and other uncomfortable details. Not only is this embarrassing, dentists could lose work and face increased insurance rates and the potential for non-renewal in the future.

3 Steps for referring to specialists

Patients often trust their dentists’ recommendations when a referral is needed. Having a trusted team of specialists and a process for referrals can set you, your patient and the specialist up for success. Here are three steps to achieve just that:

  1. Know when to do the work and when to refer it out. Working with specialists allows a general dentist to focus on their own practice so they can perform procedures that best match their preferences and skill sets. If a procedure is not within your level of knowledge, technical skill, your office’s equipment, or lab and staff support, it is best to refer your patient. If you are unsure of what to do, evaluate whether or not the procedure has an inherent high risk of complications. Some scenarios you may want to consider referring out to a specialist include:
  • Third molar extractions
  • Implant fixture placements
  • “All-On-Four” prosthetic restorations
  • Intravenous sedation

A specialist’s office would more likely be set up for success and management of problems, should they occur.

  1. Develop a relationship with your specialists. Check their credentials, look at State Board disciplinary actions, listen to feedback from your own patients and meet the provider(s) before recommending that your patient visits him or her. Determine if they meet the following criteria, through referrals from your peers, past patient experiences and more:
  • High quality of work
  • Respectful to patients
  • Good bedside manner
  • Office works well and communicates effectively with your office

Maintain independence so you can ethically choose the best fit specialist as needed. Avoid having specialists buy you lunch or gifts that could have an air of impropriety. Know that kickbacks are illegal, whether they are box seats at a baseball game or a split fee.

  1. Communicate with the specialist and relay the information to patients. Take time to speak with the specialists who your patients will ultimately use. Have a conversation with the specialist to discuss the patient’s case, get their opinion and discuss the approach to care before referring them or doing the job yourself. This simple step can help prevent issues and resolve any potential problems more quickly.

Remember to convey that information to your patient so they know what to expect. Take time to explain why they are being referred, detail the procedure to be completed, and what they should expect. Educating patients will help them be better prepared for their visit and help avoid miscommunication.

Considering adding a service to your practice?

Many dental practices now are providing additional services such as Botox. Before offering a new service know what is required beyond initial training and certification. Determine how many annual continuing education requirements need to be met. In addition, put protocols in place to keep yourself and staff up to date on industry trends. Even though it is a new service for you, you are still held to the same standard of care for that procedure as other providers who are experts. Consider additional training to have more experience before offering new services to patients.

Review your liability insurance coverage with your agent to ensure it includes the additional services you want to provide. Adding new services or an additional office location to your policy may cost an additional fee.

Whether deciding to refer out to a specialist or to perform the work yourself, or considering adding a new service, keep in mind that the highest standard of care for your patients should guide you to the best approach.

For more information on protecting your practice, contact The Professional Protector Plan® for Dentists @ 800-922-5694, or through the website:

This information is intended for informational purposes only. Nothing contained in this publication is, nor is intended to be, legal or dental advice. Professional Protector Plan for Dentists is not liable for any injury, loss, damage or expense arising out of or in connection with the use of this information.

GL and PL Together Reduce Coverage Gaps for Dentists

GL and PL Together Reduce Coverage Gaps for Dentists

While purchasing your Professional Liability and General Liability insurance from separate carriers is common, purchasing both from one carrier with a single claims team helps reduce gaps in coverage and enables a quick payout of claims.

By Sean Gleason, Cornelius Briscoe and David Simonson

As a dentist running a successful practice, you need multiple types of insurance to cover your risks and liabilities. This includes Professional Liability (PL) insurance — also known as medical malpractice insurance — to cover treatment related injury and medical negligence claims, and General Liability (GL) coverage to protect you if a bodily injury or third-party property damage claim occurs.

However, you may not be aware that many common claims can overlap across these two coverages, creating a potential nightmare when filing claims, dealing with multiple claims handlers simultaneously, uncovering coverage gaps, collecting payments from different carriers… and more!

Consider these three true claims scenarios and lessons learned:

1. A friend designs your website and uses copyrighted photos.

Many dentist practices hire professionals to create their websites. However, some turn to friends — with problematic results. In one case, the dentist’s friend unwittingly used a copyrighted image, which carried an $800 a day fine for each day it was on the website. Fortunately, the practice had coverage for copyright infringement under both its PL and GL policies.

    Take-away: Advertising coverage may be offered under both policies, but with different wording or coverage options. Having PL and GL in one package enabled the claimant to work with one claims team and have all their options for coverage reviewed and handled appropriately.

    2. A patient is injured by falling plastic.

    A patient sued his dentist, claiming he had suffered a concussion and cuts to the skin that caused scarring when a piece of plastic lens from the dental light broke off and hit him in the head and face. The incident happened when the dental practitioner was moving the light into place. Was the equipment defective (a GL claim), or was the practitioner negligent (a PL claim)?

    Take-away: There could be an overlap in coverages. If the practice has both coverages with one carrier, the claims team can manage the claim from both perspectives, investigating what the source of the falling plastic was; i.e., the equipment or the practitioner.

    3. A sedated patient falls in the bathroom.

    A sedated patient needed to use the restroom in the middle of treatment. The dental assistant helped him to the bathroom entrance. While inside, the patient fell, hit his head on the toilet and suffered a brain injury. The patient later sued, claiming he fell because he was over sedated, triggering a PL claim.

    Take-away: The claims team was able to investigate the fall to determine if the accident qualified as a PL claim due to malpractice, or a GL claim because the fall was caused by something else. As a result, the team could ensure that the appropriate coverage kicked in.

    Beware of potential gaps and exclusions

    It’s important to know where there may be gaps in coverage between PL and GL policies. An in-house claims team familiar with both will have critical insight into:

    • Concurrent policy limits that could affect coverage. Dental GL is an occurrence-based policy where claims that occur during the policy period are paid regardless of when they’re filed, versus a claims-made policy that only considers claims filed during the policy period. This can get tricky if there is an incident that continues for years or there are multiple claims that cross policy periods where there were different limits.
    • Restrictions on the number of facilities PL will cover. A dentist might practice in multiple facilities — one they own and another they practice in — but their PL could restrict their coverage to only one facility. This leaves only Dental GL to cover the exposure if PL is insured on another policy.
    • Restrictions on intellectual property. A company’s most important asset is frequently its intellectual property, covered under advertising injury coverage in a GL policy. Some GL policies may restrict coverage for personal injury, libel, slander and defamation. For example, if one dentist disparages another and is sued.
    • Issues arising from treating non-dental problems. A dentist getting involved in diagnosing an issue such as sleep apnea that should have been referred to an associate could pose a coverage gap between PL and GL insurance.

    Protect yourself and your practice

    Every dentist has either experienced or worried about these or other troubling scenarios.

    What will you do if faced with such a claim? Do you understand the coverages you have and where there may be overlaps or gaps? Are you confident you will get the support you need with the carriers you have?

    If not, look for another way. Consider a carrier that offers both PL and GL coverage.

    For more information about using one carrier for both your Professional Liability and General Liability coverage needs, contact PPP Risk Management.

    This information is intended for informational purposes only. Nothing contained in this publication is, nor is intended to be, legal or dental advice. Professional Protector Plan for Dentists is not liable for any injury, loss, damage or expense arising out of or in connection with the use of this information.

    How to Hire and Retain Dental Staff for the Long Term

    How to Hire and Retain Dental Staff for the Long Term

    Finding and keeping quality employees can be a challenge for dental practices in the post-pandemic world. Adjusting your approach to staffing and personnel management can yield positive results.

    By Dr. Ty Galvin, D.D.S., and Dr. Mike Gile, D.D.S.

    When someone utters the phrase about good help being hard to find, many dentists will agree.

    The recent COVID-19 pandemic created staffing issues for dental practices as administrative personnel and hygienists may not have returned to work once pandemic restrictions were loosened or eliminated. This phenomenon has dentists looking at hiring and retention efforts in a whole new light.

    According to a study by the American Dental Association Health Policy Institute, the labor crunch within the industry has caused an 11% reduction in dental practice capacity. Approximately 40% of all dental practices surveyed responded that they were either currently or recently recruiting dental assistants, while 36% were currently or recently recruiting hygienists. About one-third also revealed that appointment schedules are not full, due in part to inadequate staffing.

    With the staffing landscape changing, dentists recognize that changes are needed to find and retain new employees, since new hires may view a current position as a steppingstone, moving on when the opportunity to earn more money arises.

    Hire slowly, fire swiftly

    Not only is employee turnover disruptive to your practice, but it’s also costly. Recruiting and hiring a new employee can cost up to $4,700 on average.[1]

    Consider top-line dollars in the equation as well: Hygienists can generate as much as $150,000 annually in revenue for your practice. So, being short-staffed isn’t just a problem of a lack of bodies to help; it can also be an indicator of a weaker bottom line.

    As a result, you want to build a staff that exhibits three principal qualities as a whole:

    1. Stability. A busy practice needs employees who will perform tasks and duties consistently in the office. While work/life balance should be emphasized, issues like absenteeism and presenteeism must be addressed.
    • Competency. Employees need to excel in patient care and the technical aspects of their jobs. Job hopping may indicate that these skills are lacking.
    • Loyalty. New hires who readily adopt a patient-centric mentality will tend to be more engaged and focused on a long-term career. It’s essential to identify who among your staff may not be team players. 

    To minimize turnover and maximize long-term employees, take your time and consider adopting the following hiring practices:

    • Leverage multiple recruiting sites. About 25% of dental practices use recruiters.[2] Consider a standardized application and link it to job listings on Indeed, Zip Recruiter, Craigslist or publications that have wide local circulations.
    • Seek referrals from trusted sources. You may have employees, family or friends who know qualified candidates for employment. Offer a referral fee to help drive activity.
    • Create detailed job descriptions. Well-written job descriptions reflecting benefits packages may help attract top talent while dissuading unqualified prospects who take up time and resources.
    • Use a temp service. Temp agencies can help pre-screen applicants, so you have a good sense of whether the person is a fit. Fees for this service pale in comparison to lost revenue from understaffing.
    • Beware of hiring other dentists’ employees. Poaching employees from others could harm your reputation in the professional community.
    • Connect with local training facilities. You can find a steady stream of prospects through college or trade school programs conducted near your office.

    If an employee is not working out, it’s best to terminate the relationship quickly. Here are some signs that an employee is not the right fit:

    • A general feeling. While running a practice and working alongside many types of people, you often instinctually know if a specific employee is not meeting your expectations. We need to give employees a chance, but if they aren’t a fit, don’t let them linger.
    • A lack of chemistry. You’re in an industry in which “people skills” resonate. Employees who clash with fellow employees and/or patients likely won’t work out in the long run.
    • Poor job performance. You have quality standards for services, procedures and outcomes. If performance falls short of those standards, it’s another indication that termination may be necessary.

    Use probationary periods to set a time during which a new hire’s performance will be assessed. A 30-60-90-day probationary period can give you enough time to gauge whether an employee will work out, while allowing quick removal if they are not performing.

    3 reasons hygienists and dental assistants leave your office

    According to the ADA, there are three main reasons hygienists and dental assistants leave a job:

    • workplace culture
    • insufficient pay
    • being overworked

    Awareness of these issues can help you implement measures to prevent quality employees from leaving.[3]

    Since you spend so much time with your employees, it’s imperative to create an office culture that strives for an optimal level of work-life balance. Learning about your employees’ personal lives not only improves employee engagement, but results in greater production levels, reduced training costs and higher patient retention ratios in the process. In addition, verbally recognizing hard work and creating a comfortable office atmosphere helps increase employee satisfaction.

    Hosting team-building events outside of the office such as dinners or sporting events also gives everyone a chance to socialize and bond. Make it a point to recognize employee birthdays and work anniversaries as well to increase employee engagement.

    On the business side, actions like supporting a hygienist who may be running behind can help build loyalty. This might involve providing a sample to a patient or finding another staff member to help turn over a room. Employees are much less likely to seek employment elsewhere if they are part of a team. Wages and benefits packages also should be competitive with other practices in the area.

    Finally, management style should reflect gentle accountability. Avoid micromanaging your employees. Instead, empower them to make decisions withing the practice and encourage them to make contributions that might fall outside their designated roles. Most important, stay calm and professional while deescalating office dramas and avoiding micromanagement.  

    For more information on finding and retaining ideal employees, contact PPP Risk Management.

    [1] Society for Human Resource Management “The Real Costs of Recruitment,” April 11, 2022.

    [2] American Dental Association, “Dental Workforce Shortages: Data to Navigate Today’s Labor Market,” October 2022.

    [3] American Dental Association, “Dental Workforce Shortages: Data to Navigate Today’s Labor Market,” October 2022.

    This information is intended for informational purposes only. Nothing contained in this publication is, nor is intended to be, legal or dental advice. Professional Protector Plan for Dentists is not liable for any injury, loss, damage or expense arising out of or in connection with the use of this information.

    GL and PL Together Reduce Coverage Gaps for Dentists

    The Professional Protector Plan® for Dentists announces new brand and website launch

    The Professional Protector Plan® for Dentists (PPP) announced today the launch of its newly designed brand and website at The PPP provides dental malpractice insurance, including professional liability, general liability, property coverage, employment practices and a comprehensive risk management program for dentists in all career stages.The new website is more accessible and modernized, making it easy for dentists to find the information they need.

    “Our website is designed to be more contemporary and user-friendly, with an improved site navigation for our guests,” said Mike Wensel, V.P. Program Leader of the Professional Protector Plan for Dentists. “We want our dentists to have a positive experience when visiting our site, as illustrated by the enhanced brand design that better represents our company’s values. We are also excited to share our new PPP Pillars of Strength – Prevention, Protection and Peace of Mind.”

    Some new pages on the website include a “Who You Are” page where dentists can easily navigate product offerings by the type of practitioner, as well as a “Who We Are” page that introduces PPP’s program leader, Mike Wensel, and state and national advisory board members. The Risk Management page also provides a robust selection of resources for insureds to become a “Proactive Practice,” with information about continuing education courses, articles, and sample letters and forms.

    The PPP’s new website will be regularly updated with news and insights, articles, new product offerings and risk management resources. Visitors are encouraged to explore the website, receive a quote and find an agent at They can also visit the PPP’s social media channels for more updates—PPP can be found on Facebook, Instagram, LinkedIn, Twitter and YouTube.

    About Professional Protector Plan for Dentists®

    Through its network of specialized agents, the PPP has been serving dentists nationwide since 1969. This comprehensive insurance program was developed specifically for the dental practice. The plan is offered in all 50 states plus the District of Columbia, Puerto Rico and the Virgin Islands. The Professional Protector Plan for Dentists® is a division of Protector Plans, a wholly owned subsidiary of Brown & Brown, Inc. For more information on the insurance products for dentists and risk management services the PPP has to offer, please visit

    About Brown & Brown, Inc.

    Brown & Brown, Inc. (NYSE: BRO) is a leading insurance brokerage firm, delivering risk management solutions to individuals and businesses since 1939. With 15,000+ teammates in 500+ locations worldwide, we are committed to providing innovative strategies to help protect what our customers value most. For more information or to find an office near you, please visit

    Click here for the full press release.

    This information is intended for informational purposes only. Professional Protector Plan for Dentists is not liable for any loss or damage arising out of or in connection with the use of this information.

    When should you refund a dissatisfied patient?

    When should you refund a dissatisfied patient?

    Issuing refunds to patients is not out of the ordinary for dental practices. To protect your livelihood, you will want to follow some prescribed guidelines, reducing the chances of an unhappy customer filing a malpractice claim.

    By Ty M. Galvin, D.D.S., and Michael A. Gile, D.D.S

    Dentists understand they must issue refunds to unhappy patients from time to time. It’s not an unusual circumstance nor should it be disruptive to your practice. Maybe you performed a basic service that ultimately wasn’t covered by the patient’s insurance, or a structural issue arose with a crown or bridge that you feel responsible for.

    In these cases, there are ways to reduce your liability and still defuse the situation when offering out-of-pocket dollars back to the patient.

    5 steps to processing a refund

    In your practice, you’ve come to know many patients — some better than others. If a refund request occurs, you might be tempted to write a check and quickly put the incident behind you. But this could pose a problem regardless of how well you know the patient. So, it’s prudent to establish and consistently abide by a formal process for refunds. Here’s how.

    1.     Determine the reason for the refund.

    Before issuing a refund, investigate the reason for the patient request and determine the validity of the patient claim. That starts with a basic fact find. A patient’s concerns will usually be conveyed via an initial phone call or email to your office. Make it a point to have your staff gather as much information as possible about the issue when this occurs.

    You’ll then need to review the facts before deciding to provide a refund. It may be a snap decision to refund $40 for a fluoride treatment that’s not covered by insurance, but refunding the full cost of an implant will warrant a more thorough review. 

     2.     Search for an alternate resolution to the issue.

    Money may not be the only remedy to a patient’s dissatisfaction. If the issue pertains to reconstructive dental work you performed, addressing and fixing the perceived issue with a tooth, bridge or crown might alleviate the concern. When the patient recognizes that you’re taking every conceivable step to correct the problem, your goodwill could be enough to make everything right.

    Your ultimate goal is to make the patient happy, but in some cases that objective may be unrealistic. Some individuals may persist with their claim to a refund despite your best efforts to placate them.

    3.     Document every step of the process.

    It’s critical to gather all pertinent information surrounding the frustrated patient’s experience. Document each communication between the patient and your office, noting the date, time and specific details of conversations and emails. Make sure to log all work performed or discussed in the patient’s chart.

    Make note of the patient’s demeanor during face-to-face meetings or phone calls as well and use neutral language when interpreting or documenting their behavior. Observing hostile or irrational behavior may not cloud the facts of an issue but documenting state of mind could have some bearing on outcomes — if the dispute finds its way into the legal system.

    4.     Incorporate a formal release document into the refund process.

    If the patient agrees to a settlement, refunding or waiving a payment is only one part of the deal. Formalizing the terms in writing could help deter any further action taken on the patient’s behalf. In some instances, you may simply be forgiving a balance due but before writing a check, obtain a signed release, which could help permanently close the case, or provide the necessary documentation should it proceed to a claim, lawsuit, or State Board action.

    The release form is a document the patient signs to lessen the risk of litigation or a board complaint. A signed release should be secured before you refund a patient. Asking for a signature on a release could trigger an unpleasant reaction from an aggrieved patient. Faced with that possibility, you might look for another way to diffuse the situation.

    Note that the general release form should be recreated on your office’s letterhead. If you mail the release to the patient to sign, include a self-addressed envelope to make the process easier for them, along with a letter that notes the following information:

    • The refund won’t be processed without a signature on the release
    • A mention that a payment removes your office from any future liability
    • A time frame within which the release must be signed and returned

    You don’t need to self-report a simple refund to the National Practitioner Data Bank, but payments from state law actions or lawsuits must be.

    5.     Stay mindful of potential malpractice claims.

    Malpractice claims are an unlikely result of a refund request, but the possibility can’t be entirely dismissed. A simple refund process won’t require you to contact your insurance broker or carrier, but escalation beyond an open and shut case will mandate a notification.

    Two occurrences indicate that the patient may be pursuing legal action: If you receive notice from an attorney representing the patient, and/or the patient turns the matter over to the state dental board. If faced with either of these consequences, inform your broker or carrier immediately.

    It goes with the territory

    Unhappy patients are just part of the landscape of having a dental practice, and sometimes you simply have to sever ties with them. Consider these mildly unpleasant circumstances a cost of doing business. You can hope that refund requests get resolved quickly and simply but be wary of how dissatisfaction might turn into something more complex and costly.

    For more information on how to protect yourself from unwanted claims, contact PPP Risk Management.

    This information is intended for informational purposes only. Professional Protector Plan for Dentists is not liable for any loss or damage arising out of or in connection with the use of this information.