by Paul D. Zuelke

Is the title of this article just more (and typical) hyperbole? Is there really only one answer to generating great case acceptance, being highly profitable, getting rid of patient delinquency, and truly enjoying a wonderful quality of life within your practice? No, of course, there is not, but you can go a very long way toward accomplishing each of these three goals by going back to some very basic practice-management policies.

The greatest single barrier to your patients’ ability to say “Yes!” to your orthodontic diagnosis and treatment plan is their ability to afford your orthodontic fee. In order to sell an elective product you must make it easy for your customers (patients) to pay for what you want them to buy.

Thirty and more years ago, orthodontists routinely granted liberal in-office payment plans to their patients. But during the past 10 years (and especially the past 3 years of our economic downturn), more and more orthodontic practices have become almost “cash only.” These practices depend on third-party finance companies, credit cards, mandatory auto-debit, and their patients’/parents’ wealth to ensure case acceptance. Most orthodontists who have continued to grant in-office credit have done so only with very large down payments and restrictive monthly payment plans.

Could this shift in payment policies be the reason that case acceptance rates today are as low as they have ever been and are a good deal lower than those of 30+ years ago? The only growth many practices have seen over the past 10 years has been due to fee increases, and the most recent 3 years have seen 20%+ declines in new patient flow and declines in the percentage of exams starting treatment as well.

Orthodontic Economics

This fundamental change in how orthodontists handle their patient financial policies started some time ago, as a shift seemed to occur in the basic integrity of some patients. Thirty years ago, it was relatively uncommon to have a patient’s account go unpaid, so granting in-office credit, including $0 down-payment credit, to patients was a common and quite safe policy. But for some years now, granting internal credit has no longer felt like a safe thing to do for many orthodontists. Many doctors have noticed that every time they take a risk with that “special” patient—the one they just knew would pay—the account became delinquent and the relationship with the patient turned sour as well. Not only did the practice not get paid, but quite often they also lost the patient—and they certainly lost patient referrals! For a bit of icing on the cake, the majority of malpractice cases are also filed by delinquent patients.

During these same years, however, including the most recent 3 years, quite a number of orthodontists have continued to grant liberal in-office credit to their patients, and they have done so safely and effectively. These practices operate in a delinquency-free environment, and both their new-patient flow and their rates of case acceptance have greatly exceeded that of the “typical” practitioner, even in our trashed economy. Are these doctors just lucky? Do they practice in a paradise of nothing but perfect patients?

Credit with a Twist

What is happening in these practices is almost incredibly simple. Recognizing that their diagnoses and treatment plans are elective to the patients, recognizing that large numbers of parents/patients are simply not in a position to be able to pay large down payments for their orthodontic care, and recognizing that 75% of all patients offered third-party financing reject that option, these orthodontists simply chose to grant in-house credit to their patients … but with a twist.

These orthodontists choose to use the same technology used by virtually all other lenders in the country. They make a formal credit decision on each of their patients and grant credit in a manner that is appropriate to the risk presented by the patient. These practices are liberal and flexible in granting credit—even $0 down-payment credit in the rare times when it is necessary—to their patients who are mature, stable, and who live a life of integrity. They do not grant liberal credit to the patients who are not that way. The key, of course, is that they know the difference.

What would you estimate the dollar value to be of knowing, for certain, that the new patient you are seeing today has 20 years of impeccable credit and has never failed to keep his financial commitments to any creditor? Doesn’t a policy of requiring a 25% down payment for such a patient seem foolish?

What would you estimate the dollar value to be of knowing, for certain, that the new patient you are seeing today has 20 years of history of never paying his bills and has broken nearly every financial agreement he has ever made? Doesn’t a policy of scheduling a 2-hour banding appointment—and expecting a down payment to be made at that appointment—seem just as foolish?

What is the value of knowing that you can safely quote a $5,800 orthodontic fee and allow $0 down payment and 30 monthly payments even though you have a 24-month treatment plan? What if you are offering Invisalign, SureSmile, or other short-treatment-time options and offer tremendously flexible financial arrangements to those patients? What percentage of the public who may choose to visit an orthodontist can afford to pay such a case fee over 12 to 15 months? The answer is very darn few.

What if you could spend less than $6 and, in 30 seconds, know exactly the credit rating of any patient/parent and obtain a specific recommendation regarding the minimum down payment and the maximum contract length that should be offered to that patient?

To read more articles by Zuelke, in our online archives.

Recent technology has made the decision to grant credit much easier. The Zuelke Automated Credit Coach (ZACC), offered through OrthoBanc, is a Web-based computer program that allows practices to obtain and evaluate a person’s maturity, stability, and financial integrity as determined by his credit report. ZACC returns a specific, highly accurate credit decision, specifically designed for orthodontics, that includes a recommendation regarding the most liberal financial arrangement that particular person should be offered.

A ZACC inquiry does not impact a patient’s credit score and never shows up as an inquiry when other lenders obtain a credit report on your patient. ZACC was designed specifically for the orthodontic profession and is in use every day by many orthodontists.

Paul D. Zuelke is the owner of Zuelke & Associates Inc, an orthodontic consulting firm in Portland, Ore. He has a financial interest in products mentioned here. He can be reached at