bearsky23 / iStock / Getty Images Plus
Tug
Tug
Tug
Tug
Tug

Street-smart PPO plays

June 22, 2023
Many dentists feel the pressures that belonging to dental insurance plans often bring. Looking at PPOs through this adviser’s lens may help you make better choices for your practice and your patients.

I field calls from dentists across the US who are wrestling with PPOs. Many of these dentists are writing off tens of thousands of dollars per month. Most of them are working about one-third of the day (or more) for free due to insurance write-offs.

Of course, because of inflationary pressures, especially wages, dentists would like to increase their fees, but that doesn’t help if 80% of your business comes from PPOs. In these cases, the only way you can have control of your fees is by strategically and safely cutting back or pushing back on PPOs until you reach a balance of participation and reimbursement.

No smart practice owner can neglect managing their PPO participation. Here are some key points:

Know who you’re contracted with and what it’s costing

We prefer that clients try to charge out their real, standard fees and do the appropriate credit adjustment once they receive the insurance check. Have specific credit adjustment codes for each of the major PPOs you participate in—e.g., Delta, MetLife, BCBS, etc. Don’t just use one code for all insurance adjustments.

If yours is one of the many practices that charges out the insurance company fees depending on your practice management software, it can be much harder to see what PPOs are actually costing you. But it isn’t hard to see just by looking at the PPO fee schedules that 40% discounts are costing you plenty!

Direct participation or umbrella groups?

You can be directly contracted with PPOs, such as MetLife, Cigna, Guardian, Humana, etc., or you can be indirectly engaged with them through a “leased network” arrangement, such as Connection, Careington, DenteMax, Sun Life, etc. The insurance industry has set things up so that whether you are direct or indirect, whichever route pays less is what you’ll get.

You may also be interested in ... Tired of outrunning PPO discounts? 

Umbrella groups often have a similar collection of PPOs. Some groups pay better than others, and it can vary by region. Generally, it doesn’t make sense to be involved in more than one umbrella group. You’ll want to be with the one that has the best fee schedule and the PPOs that are active in your area.

There are excellent companies that can help you sort out umbrella networks. Increasingly, they don’t use the word negotiation; they use optimize instead. Basically, they shop the networks for you and figure out the best deal. They can do this much more efficiently than you or I could.

Is your hygiene department locked up?

Every week, I hear from offices where it can take months for a new patient to get in. They are short on hygienists and either can’t add additional team members or just don’t have the room to do so. Sometimes the doctors simply don’t want to do more hygiene checks. For most GPs, checking two hygienists per hour is enough.

It’s ironic that the dentist is busy working for deep discounts while patients who could pay more or even the full fee might have to wait months to get an appointment. If you’re maxed out, why are you working at a discount? Let me repeat that: If you are maxed out, why are you working at a discount? It’s time to balance supply and demand, which leads to the next point.

It’s not all or nothing

You don’t have to go completely insurance free to improve your situation. Most doctors participate in more than one plan or a network of plans. You can even carve out plans within a network and transition them one at a time.

You may also be interested in ... Will high inflation be the end of PPOs?

When I talk to doctors who want to drop “The Big One,” I often suggest that they do a warm-up play with a smaller PPO first. That way your staff can learn how to plan for a transition and work out how they’re going to effectively communicate with patients about it.

With any PPO transition, there will be a loss of patients. However, if you’ve done your groundwork and your staff is trained, you’ll be surprised how many patients choose to stay with you. We’ve found repeatedly that patients like their dentist for more than their in-network participation. And although insurance participation is a source of new patients, it isn’t the only source or even the major one. If you are a dentist in independent private practice, your major source of new patients is referrals, right?

It’s a lot easier to sign up with PPOs than get off them. You must accept a certain degree of unpredictability as you go through these transitions. If you want predictability, stay with all the PPOs you are with, and you’ll continue to write off tens of thousands of dollars every year.

It’s not always just about hard work, integrity, and skill

Dentists and teams are generally hardworking, caring people. They take pride in the quality of care they deliver, continuing education, technology, and clinical skills. But there comes a point when they just can’t run any faster and maintain their quality of life or the quality of their patient care. If dentists aren’t careful, they can inadvertently create the sort of environment where patients only like them for their in-network status.

You’ve made bigger decisions in your dental career. Remember the courage it took to buy your office, do an expansion, add an associate, and set off on your dental career? A little courage can go a long way in closing the gap between what you do and what you get paid for.

Cigna games

In the past, Cigna has had widely varying fee schedules for general practices. Some practices were paid very well, while others had PPO discounts of 35% or more.

In the past couple of years, Cigna has sent letters to many doctors announcing that they are going to reduce their reimbursement. These dentists have to decide whether to lump it or leave it. Often, when dentists decide to send in a drop notice, Cigna comes up on their fees. It becomes like a big poker game with them.

Cigna dental insurance has widely variable out-of-network benefits. Some of the benefits are surprisingly good and, therefore, patient retention remains strong. But some aren’t. It varies by location. When Cigna changes the deal by reducing an already low fee schedule, it’s fair for you to say “no deal.” Doctors with a plan can deal with Cigna.

Playing it smart with Delta

Roughly speaking, participation with Delta Premier is expensive—a 25%–30% discount for most practices. However, Delta PPO discounts are significantly more in most states: approximately 35%–45%. If you have dual status—that is, if you are contracted with both the Premier and PPO plans—it makes sense to take a very serious look at dropping the PPO. Most of your patients will default to the Premier status and fee level, which results in a significant increase in income for your practice. Patients still get very good insurance through Delta, and it still costs you to participate, yet you’ll add thousands to your bottom line. Participation with Delta PPO doesn’t help practices attract and keep enough patients to make the extra level of discounts worth it.

Many doctors think they can’t do this, but in most states you can! In many states, new doctors must be with the PPO; they can’t choose to be Premier only. But, many times, the senior doctors can! The senior doctor can move to Premier status while the junior doctor stays on the PPO contract. It can be confusing and takes some sorting out, but the additional revenues can be substantial. Don’t assume you can’t make this work for you. Every month, I talk to dentists who are unaware of their Delta status and their options. Check it out!

MetLife, Aetna, and others

Keep in mind that many of these dental insurance companies sell medical insurance. Dental is an add-on for them. Although they take their dental business seriously, it isn’t necessarily their core business. The fact that they have entered the field has forced Delta to compete with these other insurance companies, and Delta will use that to justify why they must keep reimbursements to dentists lower than dentists would like to see.

In most situations, these plans do not hold the majority of a practice’s patients. They can sometimes pay less than 60% of reasonable fees in-network but are surprisingly reasonable out-of-network. It all depends on the dentist’s local insurance environment.

Your strength

Insurance companies have massive amounts of capital, people, and resources. To a dentist, it can feel like a David and Goliath relationship. Keep in mind that you have a key asset: you are the one who has the relationship with the patient. Most patients trust you more than they trust their insurance companies. However, your tight relationship with patients can also work against you. Even though it makes business sense, no one likes to see patients leave, even when they have too many patients. I call this the “Anderson Effect,” because even though it might make sense mathematically to leave a PPO, you hate to lose the “Anderson Family” because your kids play soccer together and you go to the same church. The insurance company doesn’t have the advantage or disadvantage of knowing the patient.

You have more power than you think

If you apply thought and planning, you can start wrestling back control of your fees and your practice. Disabuse yourself of trying to outrun discounts, thinking patients only come to you because of your insurance participation. Don’t think you must write off tens of thousands per month to be successful. You don’t have to be a purist, but you don’t have to be in pure hell either. As Ann Landers said, “No one can take advantage of you without your permission.”

Dental insurance is good

Despite the struggles, there’s no question that dental insurance has done much for the health of patients and the economic vitality of practices across the US. It’s been a major factor in the expansion and upgrading of dentistry since the 1950s. Insurance companies have their own business challenges as well.

When dealing with insurance issues, always stress the positive: “The good thing about MetLife is that you can go to the doctor of your choice.” “Your Cigna plan has good out-of-network benefits.” “Dental insurance may not cover everything but you’re lucky to have it.” Never slam the insurance company. It’s not helpful, and everyone fares better if you keep the messaging upbeat. 

Editor’s note: These statements are the opinion of the author and do not necessarily reflect the opinions of Dental Economics, Advanced Practice Management, or any other entity. Advanced Practice Management is a recent financial supporter of Dental Economics. This article appeared in the June 2023 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.