Escaping Dental PPO Contracts Pt. 1: Is It Ever a Good Idea?

Do out-of-network dental providers make more money? Sometimes.

It isn’t controversial to say that many dental professionals aren’t happy with their insurance contracts. And they have good reasons not to be.

Contract terms that allow companies to downgrade, bundle, or deny coverage outright.

The complicated carrier-payer relationships that make it almost impossible to predict either how much you’ll get reimbursed, or how much your patients will actually owe.

The difficult conversations front office staff often have to have with patients who are surprised when they owe much more than they expected to.

And of course the frustrating, time-consuming process of trying to actually get real answers to important questions like “why does this EOB say you paid us more than the amount we actually received as a deposit?”

If any of that sounds familiar, you’re not alone. All of these issues are both very common and incredibly frustrating. You’re also not alone if you’re not exactly sure what you’re supposed to do about it.

Maybe you’ve tried going through the “proper channels” before. Playing by their policies and rules, working with a third party to renegotiate your fee schedules, and then seeing no real significant changes to your revenue after all that time and effort.

Many dentists get to the end of their rope and feel like the only solution must be exiting insurance networks entirely. Terminating every contract so they can get paid full fees out-of-network and not have to deal with filing insurance claims at all.

But can it really be that simple? Won’t you lose all your patients if you leave their networks? Can doctors just start leaving networks and make more money?

The short answer is, no. It’s not simple. Dental insurance is, surprisingly, very complicated. There are a number of critical factors that dentists need to understand and be able to address in order to successfully leave unprofitable networks without completely tanking their businesses.

Can I leave low paying dental insurance networks without losing all my patients?

Many feel trapped in upside down insurance contracts by the fear that they’ll lose all their patients if they leave. And yes, this probably is the single biggest thing you need to worry about.

You can’t just exit all your contracts at once, you’ll destroy your patient base. But it is very possible to completely change your dental benefits contract situation, dramatically increasing your revenue, while also retaining the vast majority of your current patients. It just has to be done methodically, strategically, one step at a time.

I’ll go into more detail about how exactly we at S101 help our clients accomplish that over the next four parts of this blog.

But as a starting point, I’ll tell you what we tell every practice we work with. Most people choose a new dentist based on convenience. They look on Google Maps, find offices with good reviews, and then they call to ask if you take their insurance. Or they get a referral from a friend or coworker. Few people actually use the provider look up tools they have from their actual benefits company. In other words, a well-established existing practice probably doesn’t need to rely on benefits plans to help them acquire new patients.

However, patients return to your practice because they had a good experience, received high quality care, and their expectations were met when it came time to pay. Patients don’t care what networks you’re in, they care about getting their yearly two “free” cleanings/exams, and some discounts on restorative treatments. 

So how can you find a way to deliver on their expectations, while also increasing the reimbursement rates you’re getting from their benefits plans? Not having to worry so much about what their plans will cover also gives you more freedom to make the best choices for their health, as their healthcare provider, without feeling like their benefits company is in the exam room with you.

Sounds too good to be true?

It’s not. It’s not even that difficult, it’s just very complicated and time consuming. These projects take dedication, but they’re worth it. Not only do our clients experience more freedom in how they practice dentistry, but they gain more control over their businesses. Our clients generally see six-figure increases to their annual revenue. Not production, practice revenue. 

How can a dental practice increase revenue by exiting insurance contracts?

The solution isn’t to renegotiate your fee schedules or to raise your office fees, and it also isn’t to go totally out-of-network. The problem isn’t that your UCR fees are too low, and it also isn’t that every single network contract available is automatically terrible.

The problem is that you aren’t getting paid as much as you should be.

Our goal at Solutions 101 is to fix that problem in whatever way we have to. If that means taking you out-of-network with one carrier, and then repositioning your contract or renegotiating your fees with another, it doesn’t make a difference to us. We care about helping you get paid as much as possible, regardless of your network status with any given carrier.

Some of your contracts are probably not worth salvaging, and you would make more if you treated patients with those plans as an out of network provider. Other plans could potentially pay you very well, if you’re able to maneuver your contracts the right way. It depends on your location, the plans your patients have, and your patient saturation within each of those plans. Every practice is in a totally unique situation, there is no one-size-fits-all answer.

For most of our clients, the ideal solution typically ends up being negotiating higher fee schedules with two or three carriers, and going out of network with the rest.

How do you know which contracts to drop, which ones to stay in, and what order you should make changes in?

In order to leave unprofitable contracts without losing your patients, and in order to determine which networks you should leave and which you should stay in, you’ll have to understand:

  • The differences between self funded and fully insured plans, and why that matters to your business
  • What plans your patients are bringing into your office, what contracts those plans fall under, and what percentage of each contract those plans comprise.
  • The Max Allowable Charges – in and out of network – that each plan in your office is willing to pay
  • Which plans lease their networks and which don’t
  • Which carriers network together, and whether those are one-way or mutual connections
  • The specific process required for successfully terminating each contract, because each carrier has slightly different policies, requirements, and hoops to jump through before they’ll let you leave.
  • How to track your progress and ensure each carrier is compliant with the terms of your contract with them

I’ll address each of these questions in more detail in subsequent blogs. But here’s the short version: most of these simply are not questions you’ll be able to answer on your own. If you’ve made it this far, and the process I’ve described already feels like an overwhelming mess that’s going to give you endless headaches, that’s because it is. S101 clients are only able to achieve the amazing revenue results they do because we have the experience and the data required to make it happen for them.

We think dentists go to dental school so they can practice dentistry, not to reverse engineer the dental insurance industry. We want to solve this problem for dental practice owners, not just because we actually can, but because we don’t think it’s even a problem you should have to solve in the first place.

Read Part 2 Now!