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Thinking of a DSO? Ask for what you want

April 17, 2023
In this series, Dr. Roland Caire, Jr., explores the many facets of DSOs: the good, the bad, and the ugly. In this final installment, learn what you should ask for when negotiating employment with a DSO.

In previous installments, I've noted many pros and cons of establishing a relationship with a DSO. Following is a review of some earlier points, as well as some additional suggestions on what to consider—and ask for—before entering into an employment contract with a DSO-supported practice.

Traditional benefits

Ask about all the traditional benefits available and how they’re paid. Is your health insurance covered? Are your spouse or dependent benefits covered? Is there disability coverage and long-term care? Is there life insurance coverage and if so, who determines the beneficiary? Is there a retirement plan, and does it include an employer match? And how long after termination of your employment will benefits last? (Because nothing lasts forever.)

Taxes, taxes, taxes

Your only concern should be how much will be deducted from your check for income taxes. You should also verify any other deductions that will be made, especially for traditional benefits.

Also in this series:

Who's partnering with DSOs—and why?

DSOs and the potential nightmare of parallel authority

DSOs: The devil is in the details

6 advantages of DSOs—or are they?

Professional liability

Don't fall into the trap I did with professional liability insurance in which the company paid for a claims-made policy but on termination, I was responsible for purchasing the tail. The tail turned out to cost more than twice what my occurrence policy cost.

If possible, ask for reimbursement of a plan you purchase yourself. That way you own it, at least for the term of the policy. If the company insists you use their plan and it's a claims-made policy, ask what the amount of the tail will be and have it written in the contract. If the company can't guarantee an amount, have them agree to what your portion will be in a contract. Otherwise, you’re agreeing to pay an unspecified amount.

State-of-the-art technology

Ask to see just how up-to-date their technology is. Are they paperless? Is there an intraoral scanner and/or a CAD/CAM? Digital radiographs, CBCT machine, intraoral cameras, lasers?

Also take a look at their not-so-state-of-the-art equipment. Is the office modern and clean, or does it have a dirty carpet and stained ceilings? Are the handpieces worn or hand instruments broken? The nitrous tubing cracked? Is the delivery system working properly? Is the upholstery on the treatment chairs worn or cracking? These things might seem like minor issues, but it's the environment you'll be working in and what your patients will see. It also reflects how much commitment the DSO has to pride of appearance and function.

Marketing and a steady flow of new patients

Ask about the marketing strategy. Is their marketing limited to internal actions, or do they have an aggressive social media marketing plan, or any plan at all? Where do most of their new patients come from? How many new patients come to the practice in a month? A general rule is a practice needs 25 patients per doctor to grow.

How many active patients are in the practice? A healthy practice with one doctor and one hygienist should have around 1,500. This number is easily determined using most practice management software, but that depends on whether the patient data has been entered correctly. Another useful guide is to ask to see the patient schedule for the previous month. Is the schedule filled, or are there only a few patients per day? If the schedule isn't full and you're paid on production, consider asking for a guaranteed income, not for the first months (which is common) but for at least a year or the life of your contract. The burden of attracting new patients should fall to the DSO, not to you.

Continuing education

Does the DSO provide in-house CE? If so, ask what specific topics were covered in the last four or five courses and when those were held. Ask if the courses are live, online, or both. Is there a reimbursement for outside courses in your areas of interest? Are you required to take any specific dental courses? Are there nondental training courses required by the corporation? If so, how much time will you have to devote to corporate training?

Dental supplies and dental laboratories

What dental supplies are currently in the office inventory, specifically what products? Are you able to choose supplies not on the company formulary? If not, what is involved in getting a product added to the formulary? What labs are on the preferred list? What services do they provide, and are you able to use an outside lab if a specific service isn't offered?

Professional community and mentorship

If you're new to practice, you should ask what kind of mentorship programs are available. How many other dentists or specialists will be practicing in the same location? Some DSOs provide after-hours gatherings for dentists to exchange ideas, and some have email or text groups to ask for advice.

Staff management

You should ask who your direct supervisor is, and who is in the chain of command on the DSO's business side. And you should know who to turn to if you have an issue with anyone in that chain. Also, what is the protocol for dealing with disciplinary issues, both for you and for staff members who work with you?

Work-life balance

I can't stress this enough. What days and hours are you expected to be at the office? Some offices require staff to arrive as early as 30 minutes prior to opening to prepare for the day. Will you be required to, as well? Will you be allowed break times during the day? Will you be required to work through lunch? Will you have a choice about working nights or weekends? Few DSOs will pay for vacation or leave time for providers, but will you be allowed to schedule vacation or leave time? If so, how far in advance must you give notice? What happens if you are sick and have to miss a day? Or a week?

Negotiating with insurance companies

Who is handling your credentialing with insurance companies? What types of plans does the DSO accept (PPOs, HMOs, Medicaid, Medicare Advantage)? Are you paid based on production or collection? If you're paid on collection, who is filing insurance claims? How promptly are claims filed? If narratives are required, how will you be notified?

If possible, insist on being paid based on production, not collections. Your job is to produce, not to collect. If you're paid on collections, you're dependent on the DSO to do their job in a timely fashion and you may have no control over how the process is done or who does it, so you shouldn't be penalized if the DSO fails to collect.

It sounds like a lot of questions, but I would have had a much easier time adapting to life in a DSO if I had thought to ask more up front. Don't be afraid of being judged as too inquisitive by your interviewer. You can always wait until you've been presented with a contract to ask the pertinent questions. I just accepted my first contract at face value, but I asked for concessions in my second DSO contract and they obliged. I now wish I had asked for more.

Remember when negotiating that the DSO needs you. No one in the organization produces revenue but the providers, so everyone from the CEO to the dental assistants depends on you to provide their salaries. They'll be willing to make adjustments to your contract, especially if you're specific about your requests.

With the possible concerns about DSO issues I've discussed, it would be easy to wonder why I'm still involved with one. But it’s simple: I like and respect the owner-dentist. I like the specialists, and I've found an office where I like the people working with me. And, above all, I like my patients. They keep me looking forward to working every day. If you can do that, any other problems seem minor.

Good luck to you if you decide to associate with a DSO. Use this information as a starting point in negotiating your journey. If you have any other information, experiences, or questions, just drop me an email at [email protected].

About the Author

Roland Caire, Jr., DDS, FAGD

Roland Caire, Jr., DDS, FAGD, is a practicing general dentist with over 40 years of experience. Aside from dentistry, he has extensive experience in professional music, theater, and visual arts. Combining those interests, he launched a YouTube channel to address dental questions with humor, wit, and a cast of motley characters. You can follow him there and on social media by searching for rcairedds. If you have any questions or comments, send them to [email protected].

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