Starting A New Dental or Dental Specialty Practice? Will Participation With Dental PPOs Be Part Of It?
Starting a dental practice is a big project! Amongst all the questions about equipment, technology, hiring a team, practice management software, marketing and how you will operate is an extremely important issue that is a challenge for most dentists — participation and credentialing with dental insurance.
In most cases, 90 to 120 days is devoted to PPO fee negotiation time. Remember, fee negotiation is a long process because the insurance companies are not in a rush to improve or offer higher reimbursement and there are numerous obstacles to work through. Additionally, it is important to assess each offer as it comes in to determine the financial impact, but also to determine if staying with the PPO plan makes sense.
The process of PPO optimization is almost always longer than just PPO negotiation because, while important, PPO fee negotiation is just one of many strategies that are typically pursued to improve PPO profits. We always remind dentists – the objective is to have the BEST result, and NOT the fastest!
If you are starting a new practice, we can help by acting as a dental PPO fee negotiator and PPO optimization consultant in several areas including:
- Researching the largest employers in your area to determine which dental PPO plans they offer to employees.
- Establishing the foundation for your practice UCR fees by doing an analysis of area fees being charged to assist in determining what your office fees will be along with identifying the key procedures and ADA codes that will drive revenue for your practice.
- A top-notch dental fee negotiation will initiate contact and represent the dentist/practice with the various insurance companies with which the doctor could participate as a preferred provider, including handling (on your behalf) communication with insurance company recruiters and negotiation of PPO fees.
- Explore and advise on options for use of umbrella plans like Dentemax, Connection Dental, Maverest, Premier Dental Group, Zelis and Careington.
- Examine and share with the practice the various options to participate in higher fee tiers that exist within some PPO networks such as Cigna DPPO and Cigna Advantage, Delta PPO or Delta Premier, Metlife PDP or Metlife PDP plus, Anthem 100, 200, 300, and others.
- Consult with the doctor on the different PPO options and opportunities to help the doctor make the best decisions for the practice including direct contracts, third-party administrators and network sharing, as well as which networks will not offer a fee schedule that allows a reasonable amount of profit to be earned when treating members.
- Consult with the practice on PPO related topics including non-covered service laws in your state, how to treatment plan and bill when out-of-network, and software set up to maximize insurance PPO reimbursement.
- Handle the PPO credentialing process including acquisition of necessary documentation, completion of applications, submission, requests for additional information, and follow up.
- Share with team the specifics of which PPO plans are, or have been joined, and at which level, notify the dental team of effective dates of PPO participation. Once participation has been confirmed the dental team then simply needs to confirm that the assigned PPO fees are entered into the practice management software. (Whether that is Eaglesoft by Patterson Dental, Dentrix by Henry Schein, Open Dental, etc. we do suggest a quality management software, at it is an excellent investment)
- For many dentists who are wanting to take a wide-range of PPOs the exploration and/or negotiation and PPO credentialing process will include a mix of PPO plans including Aetna, Ameritas, Assurant DHA, Blue Cross or Blue Shield Dental, Cigna, Connection Dental, Delta, Dentemax, Dental Network of America, Guardian Dental, Humana, Lincoln, Metlife Dental, Principal, Sunlife, Tricare Dental, Total Dental Administrators, United Concordia or United Healthcare Dental PPO. We will work with you to ensure that those goals are met, and you are in the best possible position for optimized PPO participation.
- Once PPO participation has been confirmed, and the fees are active and in place it is also important to confirm via review of the dental insurance EOBs (explanation of benefits) that the correct PPO reimbursement rates are being utilized. Unfortunately, insurance companies do make mistakes and it is important to confirm that your negotiated PPO fees are indeed being used when the insurance company processed the claim!
When exploring, negotiating PPO fees, and doing the PPO credentialing we are firm believers in doing it right – and not just trying to do it as fast as possible. Too many times we have seen doctors who simply credentialed with many PPOs without understanding their options or taking the time to negotiate the PPO fees. The result is predictable but still disappointing – a practice that loses a significant amount of profit by having PPO fees that are lower than necessary.
But what does “significant” mean when it comes to PPO fees? Significant is the difference to us of a $1000 crown versus a $650 crown….and that amount of variance is not uncommon. That lost $350 is the profit that should have been going to the doctor if the PPO fees had been set up in the most ideal manner! The take-away? It pays to take your time and have it done right!
So, what is a reasonable period? We often suggest 30 -60 days is an appropriate time to explore and negotiate PPO fees and then choose which plans will be a good fit.
Once the PPO plans have been chosen that is followed by the credentialing stage which is typically 60-90 days for processing of applications, although in some cases it may be up to 180 days!
Why is PPO Participation Important For Many Dental Practice Startups?
Many dentists find (especially with a practice startup in an area where there is competition) that participation with insurance PPOs is important. In some cases, many dentists consider PPO participation a necessity because for many patients in-network status with their dental plan is a significant factor in choosing a new dentist. Unfortunately, the number of dental PPOs has dramatically increased as have the level of complexity, shared PPO networks tiers, networks, and participation options. Simply put, insurance participation as an in-network provider has never been more time-consuming and challenging!
Part of the frustration for many dentists in choosing to participate, sign up and credential with dental PPOs is which networks to choose. Did you know there are dozens of different PPOs in dentistry today? For example, should a doctor sign up with Metlife PDP or Metlife PDP Plus? Delta Premier or Delta PPO?
What about an umbrella plan like Connection Dental, Zelis or Dentemax that has relationship with many different companies like the Aetna PPO, Guardian PPO, Humana, Principal PPO, or United Healthcare PPO? Or linked networks like United Concordia and Principal or United Concordia and Dental Network of America, or United Concordia and Ameritas?
Does it make sense to sign up with the Cigna DPPO level or the Cigna Advantage level?
Does all this sound confusing? Well it certainly can be, with so many insurances and so many options there are a lot of things to consider! Unfortunately, the difference between just credentialing with a dental PPO and signing up in fee optimized manner for participation often equates to several million dollars of lost profit over the course of a dentist’s career!
Helping a dentist to start up in the most profitable way is a key function of an experienced dental fee negotiator. While negotiating dental PPO fees is not a fast, fun, or easy process it is crucial for a doctor taking PPOs…. there are often HUGE differences in PPO fee schedules.
What Information Will Be Needed?
A tax identification number and the address of where your practice will be located, are at minimum, typically needed to start discussions with insurance companies. Having the practice UCR fee schedule set early in the process allows those fees to be shared with insurance PPOs. Additionally, a practice phone number will be necessary for the credentialing process. Of course, a valid license and malpractice insurance policy is a necessity but is not needed to begin the PPO negotiation and exploration process.
Will All Dental PPOs Negotiate Fees?
No, not all companies will renegotiate fees, and those that will are typically impacted by local market factors. The good news is that many dental insurance PPOs will negotiate fees and that many options exist for consideration when starting a practice.
Starting a practice is a huge project and the configuration and participation with insurance plans – both in and out of network – plays a huge role in the practice profitability and ability to attract new patients. Done incorrectly a doctor signing up for plans the wrong way – whether direct, through a network share or a third-party administrator – the impact over many years on a practice is huge.
Our role at Profitable PPOs, acting on your behalf as PPO negotiators and optimization specialists, is to understand your practice goals, explore and negotiate PPO fees and credential you so that your practice startup can proceed in an organized, effective and profitable manner!
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