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How to Choose the Best PPO Negotiator

July 29, 2022

If you desire to be an in-network (PPO) provider, it is of utmost importance to negotiate fees for your participation right from the beginning. Once you have made the decision to become an in-network provider, you want to negotiate your initial contract and fees as quickly as possible, as becoming credentialed and actually gaining in-network status can take 90-120 days. Most contracts are for a term of 18 to 24 months. Be sure to make a note on your calendar when fees may be re-negotiated and allow plenty of time for this process. Or you may want to hire the best PPO negotiator.

Take the following steps before deciding to join a PPO:

Review the Plan Carefully

Make sure the PPO you are considering covers procedures offered by your practice. It may be a good idea to contact the PPO and request their most current contract, a copy of their processing policy, and the in-network fee schedule. Consider these things carefully to make sure your dental practice and the PPO are compatible. Ask the best PPO negotiator to help review the plan.

Know Your PPO Patient Coverage

The decision you make now will have a great impact on your bottom line in the future. As a result, you may want to determine the number of patients you have who are covered by each PPO plan before you decide on a particular PPO. The success of your practice depends upon this decision.

Setting Your UCR Fees

Get an idea of the fees for services of other dental offices in your immediate geographical area. A good place to begin is in the 80th percentile of others in the area. You do not want to set your fees too low, as you will be re-negotiating the fees in the future. It is important to have some bargaining power and room to negotiate an increase in fees in the future.

Know the PPO Plans Offered In the Target Patient Area

Make a list of the largest employers in your target area for patients such as schools, hospitals, federal, and state offices. Contact their human resources departments and inquire who holds the contract for their dental benefits. Joining these PPOs would be a great way to gain new patients for your practice.

Organize Plan Information Being Considered

As you continue to gather plan information from a variety of PPOs, keep all information organized in some type of folder. As you accept assignments from networks, move your contracts and fee schedules to a large binder with dividers for each insurance carrier. Be sure to label the dates of re-negotiation where they can be seen easily.

List Your Practice’s Top 30 Production Codes

Most dental practices can account for the top 90% of their billable production with 30 codes. If your practice is set up with a program to determine such percentages, you may be able to access a report to determine this figure. If you have prepared a list, you can compare PPOs that offer coverage for your most frequently billed services.

List Negotiating Leverages In Your Favor

Some things to consider as you negotiate your contract and fees with a PPO are the number of dental professionals in your area, specialties offered, hours of availability, teledentistry availability, electronic claim processing, EFT enabled, and online portals for pre-authorization. Ask if they share networks with other insurance carriers. You can always opt-out of any such agreements if you wish by writing a letter stating your opt-out preference.

Initiate Negotiations By Email

Verify any discussions you have with an email to the network recruiter. Ask for a fee schedule containing the top 30 codes from the list you created. Set a time for them to respond to your proposal. Be prepared for the fact that some insurance carriers do not negotiate. Review the fees you are offered and send in a counter-proposal if you are not satisfied. Once you do accept a fee schedule, keep a list of them. Audit your claims regularly to be sure the fees you agreed upon are being honored.

The dentist in question should negotiate their own contracts and fees with PPOs. For the most part, dentists have a much greater opportunity to attain more favorable fees. You must be persistent during the negotiation process. Organization of materials is extremely important. Remember to always be polite during this lengthy process. There is always also the possibility of staying out-of-network. If you make this decision, be prepared to treat more patients in less time. This decision gives you the freedom to treat more patients, but your fees will be lower.

If you are considering becoming a member of a PPO or dropping membership, let PPO Negotiation Solutions, the best dental PPO negotiator, assist you! Contact one of our consultants before making this critical decision for your dental practice. We can help you to work smarter and get paid better. Contact us today to schedule a consultation!

What is a UCR Fee Schedule?

July 15, 2022

The letters “UCR” in insurance stand for usual, customary, and reasonable. These are the fee guidelines by which an out-of-network dentist is allowed to charge a patient if the dentist is not a member of the patient’s PPO network. This does affect the patient’s claim payment and how much they are to pay out-of-pocket. You must properly balance your fee schedule to at least 80% in the beginning to ensure your practice remains competitive. By doing this, it allows you room for re-negotiation in the future. The dental benefit contracts you initially obtain from an insurance provider are based on your UCR fee schedule. Therefore, make sure you balance your fees before you negotiate for a PPO reimbursement contract.

Why is a UCR Fee Schedule Important?

Insurance providers control their expenses by using the UCR fee schedule. Each dental procedure is listed, as well as how much the provider has determined each procedure should cost. The benefits paid on your patient’s claim is determined by this list of fees. UCR fees are involved when using indemnity and PPO dental insurance plans. The insurance provider will pay a percentage of the cost they have determined based upon the dentist’s charges or their UCR fee for the procedure, whichever is less.

What Do Geographics Have to Do With It?

The UCR fee levels are different in each state and community. Take for instance the price of a crown is $1,000. If the percentages for the area are in the 80th percentile, it means 80% of the dentists in that state or region charge $1,000 or less for a crown.

If your dental practice is a member of the American Dental Association, you may obtain a survey which contains self-reported fees by procedure from a nationwide, random sample of dental offices. There are over 200 dental procedures listed by specialists and general dentists and their fees charged. If your practice is not a member, you may purchase this list of fees from the ADA Catalog.

However you decide to negotiate fee schedules with the PPOs in your area, it’s best to do the following idea:

call the largest employers in your vicinity
ask their Human Resources Department to which PPO they belong
check out their list of UCR fees
determine which PPOs your dental practice would be compatible with
then begin your negotiations

How Can UCR Fee Schedules Affect Dental Fees?

Based upon information obtained by the insurance company, let’s say they determine 90% of the dental offices in your area charge $1,000 or less for a crown; then the UCR fee for dental crowns most probably will be set at $1,000. If you charge your patient $800 for a dental crown, the insurance company will pay 50%. And then your client will pay 50% of your bill out-of-pocket. On the other hand, if your dental practice charges $1,200 for the crown, the insurance company will only pay 50% of their $1,000 UCR fee to your practice. Which leaves the patient responsible for the remaining $700 out-of-pocket. There does seem to be a wide fluctuation in charges without any regulation as to how an insurance company decides their calculation.

In the case of a more popular insurance company in your area, it would seem their UCR fee schedule could affect the area prices for dental services. But your practice does not want to be known for charging more than the other dental practices in the nearby vicinity. So the use of UCR fees does help keep the prices charged by all dentists in your area in line. Also, if you decide your fees are short of the UCR fee set by other dentists in your area of operation, this allows you to raise them. Or in the alternative, if your dental practice offers a unique experience, you may decide it justifies your higher fees.

In the end, the total benefits under a policy are usually limited by a deductible and a yearly maximum of payment, so your patients will ultimately have to determine the price they are willing to pay for their services.

PPO Negotiation Solutions can help you determine proper UCR fees and keep them balanced well, as well as increase your dental practice revenue. Do you know most dentists write off nearly 40% in PPO reimbursements per year? It also takes over 30 hours in some instances to complete the credentialing process alone to be accepted into a PPO! Also, 7 out of 10 dental offices do not set their UCR fees correctly from the beginning. We offer 30 years of experience. And as a result, there are hundreds of dental practices just like yours that trust our team as their solution. Contact us for your complimentary assessment and schedule a consultation today!

Avoid Accidental Insurance Fraud

June 20, 2022

Insurance fraud costs Americans more than $80 billion per year in higher premiums, according to the Coalition Against Insurance Fraud. Insurance fraud happens when an insurance company is deceived in order to collect money for someone who is not entitled to receive the money. This is against the law in every state, and health care fraud also falls under federal laws. In most of the United States, fraudulent insurance claims can be either a felony or a misdemeanor, depending on the nature and extent of it.

Your dental practice can accidentally commit fraud, and it’s more common than you would think. In most instances, ignorance is no excuse when it comes to committing fraud. In order to avoid the small mistakes that could cost you your license and practice, let’s review the following errors in billing.

Listing the Treating Dentist Incorrectly

To determine the fees for services that are the patient’s responsibility, the dentist signs a contract with a Preferred Provider Organization (PPO). This is an agreement to write off a certain amount of the standard fee for a service that is provided. It is fraudulent if you list the owner dentist as the dentist who treated the patient in question when it was done by an associate dentist who is not in-network with the insurance payor. Whether a provider is in-network or out-of-network affects how benefits are paid to the dentist.

If the dentist receives funds he or she is not entitled to receive, it is fraud. There are different scenarios in different states when it comes to who to list on the insurance claim as the treating provider. As a result, whoever is in charge of filing insurance claims in your office needs to be 100% correct when completing the ‘treating provider’ section on the claim form.

Accident on Dental Claim Form Becomes Fraud

If a patient comes into your dental practice and has broken a tooth due to a fall at home, you have to disclose the treatment is related to an accident. It is also important to specify whether the accident was workers compensation, an auto accident, etc. These specifics determine the type of reimbursement paid to the dentist.

It also may require it to be considered by medical or another third party before payment. Some dental programs will default and leave critical information blank. Unless someone knows to manually go into the program and change it.

Lack of Education and Training Can Lead to Potential Fraud

The most common billing mistake can lead to fraud landing a dentist in prison. Proper training is essential to preventing even the smallest of errors on a dental claim form. Remember, ignorance is not an excuse. For example, recording the name of the treating doctor as the owner of the dental practice when a locum tenens was filling in could be determined as insurance fraud. The owner of the practice needs to have an interest in all areas of the practice at all times to ensure proper procedures are being followed.

Down-Coding and Up-Coding

Inaccuracies found in coding on an insurance claim can also lead to fraud. Down-coding is reporting a lesser service was performed, which resulted in the dentist getting paid something he should not have been entitled to receive. On the other hand is a procedure called up-coding. This is reporting a procedure paid at a higher reimbursement level than what was actually performed, in order to be reimbursed more money from the insurance provider. Every dentist needs to take note and be aware of these mistakes.

Know the Rules

Education is power. It can be what saves your dental practice huge problems due to common, small mistakes. You and your dental team need to be educated and trained on the rules and regulations of insurance claim submissions and coding. This type of work is extremely tedious and meticulous. But it is essential to do it correctly to prevent the dentist/owner from losing their license or going to prison. Make certain your team is up-to-date on all the best practices to prevent common claim submission errors.

Most insurance companies do not volunteer this type of information. You must request a processing manual from the company. It will include all you need to know about the rules for submitting insurance claims correctly. There are other very simple actions of a well-intentioned dentist/owner to inadvertently commit insurance fraud. In order to avoid these types of instances and others, you must know what is in the PPO contract. Lack of knowledge can lead to very serious consequences. Take the time to learn the rules!

Consider contacting the professionals at PPO Negotiation Solutions for help. Hundreds of dental practices trust them. Their mission is to enrich your dental practice by increasing revenue and understanding. They have 30 years of experience in the field of PPO negotiations and participation. They can assist you in streamlining your daily processes. Take their complimentary assessment or schedule a consultation today!

Looking for a Permanent Dental Jobs in Michigan?

May 14, 2022

If you are hard working, dependable, and professional, and looking for a career to greatly impact your income and livelihood, the dental industry may be right for you! The team at SPS Dental Academy in Shelby Township, Michigan, provides the very best training at the lowest possible cost to you. Their students are sought after by many dental practices. Not only have their programs helped thousands of students begin their new careers in dentistry, they have raised the bar for the standard of education in the dental field. Don’t take out thousands of dollars in student loans when there is a better option. SPS Dental Academy offers their students a more affordable education while making their students more confident and successful in their dental careers.

Career as a Dental Assistant

If you are looking for a permanent dental job in the State of Michigan or elsewhere, you have a high school diploma or equivalent, and are 18 years of age, you can apply for the Dental Assistant Program at SPS Dental Academy. In addition, you must have an up-to-date immunization record and possess a government-issued photo ID.

The dental assisting program does not require prior experience in the dental field. The program is designed to provide you with all the training and knowledge you will need for a career in dental assisting. A good place to begin to find out if you will be happy and committed to becoming a dental assistant is to shadow your dentist, or family or friend who is a dentist, to get an idea if it is the career choice for you.

Important Qualities of a Dental Assistant

One of the numerous qualities that a dental assistant commonly possesses is being detail-oriented. There are specific rules and protocols a dental assistant must follow when assisting a dentist in treating a patient. They must also be knowledgeable of their scope of practice when it comes to the tasks they are allowed to perform in Michigan or other states.

Another quality they need to possess is dexterity. Dental assistants work in tight places on small parts of the body using precise instruments, so they must be good at working with their hands. Compassion is another quality that is good for a dental assistant to possess. They deal with the dentists and patients on a daily basis, and patients may be in extreme pain or distress. The dental assistant needs to be sensitive to their patient’s needs.

They must be a good listener to follow precise directions in order to help treat patients and complete essential tasks. They should be well organized, because they need to have all the correct tools in place for the dentist or hygienist to use on their patient for the procedure to be performed.

Important Information Regarding COVID-19

Before looking for permanent dental jobs in Michigan or elsewhere, you should know about current compliance regulations that are required for infection control. The recent COVID-19 pandemic caused many new protocols to be implemented for safety of both patients and team members. Many of these requirements are still in place in some dental practices, such as wearing masks and gloves when interacting with patients.

Throughout dental practices in Michigan, OSHA/MIOSHA COVID-19 compliance initiatives were implemented in 2021, and for the most part, haven’t changed. Everyone entering the office is screened and refused entry if they are suspected to be COVID-19 positive. Screening records retention is no longer in place. Patients and employees are not required to wear face coverings, regardless of vaccination status. CDC guidelines do still recommend face coverings for everyone who enters a dental setting.

Dentists may choose if they wish for face coverings to be a requirement in their dental practice. The MDA still recommends dental offices to follow CDC guidelines. There are no longer social distancing requirements in dental offices. Dental practices must continue to maintain a COVID-19 preparedness plan in the office. Dental offices must also ensure each employee receives or has received training consistent with their COVID-19 preparedness plan.

The SPS Dental Academy is committed to helping their graduates by offering employment assistance to all students. Workshops and other classes are offered for lifelong learning opportunities as well. Other dental programs are coming soon, so be sure to check their website for more opportunities in the near future or email them for more information at info@spsolutionteam.com.

How Does Negotiating Dental Fees Impact Your Business?

April 14, 2022

Due to the effects of the COVID-19 pandemic, dental offices are increasing infection control standards. The American Dental Association (ADA) has issued recommendations to control the transmission of infection, which closely align with the guidelines from the Centers for Disease Control. As a result of the new infection guidelines and the need for additional personal protective equipment, dental offices are negotiating dental fees in order to cover the cost of care increase.

Negotiating with each benefit provider for increases in fees should be done by each dentist individually. Be prepared to do your homework to have the most accurate information from everything, from a list of the strengths of your practice to which procedure codes used by your practice generate the most revenue. Be sure to be prepared to quote the exact date of the last time you negotiated dental fees with your insurance carriers and your special circumstances for re-negotiation.

Increased Profitability

Most dentists do not think of raising fees very often. However, if you never negotiate for a raise in dental fees, you cannot make the necessary improvements to allow your practice to grow and thrive. You must keep making investments to keep your current patient base and attract more patients in order to remain profitable. If fees are never increased, this limits the success of your practice. This will also begin to hurt your overall patient experience.

The result of raising fees at a reasonable rate enables you to:

continue to invest in training
invest in technology
invest in upgrades to your dental practice

Developing a fee schedule and negotiating dental fees periodically is key to the success of your practice. When fees are raised, ensure the amount is across the board for all fees. The American Dental Association offers a survey of dental fees to assist you.

Practice Growth

No matter how successful your dental practice becomes, there is always room for improvement. Your patients expect you to provide excellent service and care. A good way to continue experiencing practice growth is to keep your website current and credible. The internet is used by practically every consumer, and they need to be able to find your practice.

Another idea is to implement a patient reminder system to confirm and/or reschedule appointments. Most patients are familiar with a text-based reminder system to engage them in a familiar manner. You may want to ask each patient how they would like to receive a reminder of their next appointment. Consider new opportunities to connect with your patients and promote your office advances to them. This will make them confident in your care and build your credibility with them.

The “Bottom-Line”

Dental offices, like any other type of service-oriented business, have to make a profit to remain open. Not only do you want to remain in business, but you also want to employ talented dental professionals. Also, to stay up-to-date on the latest treatments and technology. There has to be an acceptable balance between profitability and patient well-being. In order for your practice to employ successful hygienists and provide the kind of quality care the patient expects, negotiating dental fees must be done in a knowledgeable way to create a profitable practice.

Things to consider are basic overhead such as rent, team member salaries, equipment costs, and insurance. Other things to consider are not so tangible, such as office production, dentist production, patient education, hygiene percentages, preventive percentages, and restorative percentages. These considerations should always be at the forefront when negotiating dental fees to maintain the appropriate balance between numbers and patient care. To achieve this balance, you must offer the patients care through education and prevention, which will in turn, guide them to their needed treatment plan.

As you build relationships with patients and educate them on the appropriate treatments, you build mutual trust. This adds value to the dental practice and will positively impact your patients. There are many ways to increase dental practice revenue. You as the dentist must be in the driver’s seat and have a current understanding of where your dental practice stands in regard to location, patient data, team member data, and overhead expenses in order to negotiate dental fees with providers that will continue to sustain a thriving dental practice.

One way to remain on top of the game when it comes to negotiating dental fees and “level the playing field,” so to speak, is to hire a professional to take your information and negotiate the fees on your behalf. The team at PPO Negotiation Solutions are experts in their field and have been negotiating dental fees for 30 years. They have an impeccable reputation and have the negotiation process down to a science. It will save you precious time you can devote to your patients and their care. Check out their complimentary assessment and schedule your consultation today!

What You Should Know About Insurance Negotiations

March 28, 2022

Did you know you can negotiate fee reimbursement rates with an insurance company as a dental service provider? You can and you should! Negotiated fees are fees a dentist who is “in-network” agrees to accept as payment for services provided to the patient, less co-payments, deductibles, cost sharing and benefit maximums.

Insurance companies do not pay all dentists the same for the same exact services they each provide. Every extra dollar your dental practice negotiates with an insurance company for services rendered is another dollar in your pocket. Negotiated fees are subject to change, as they can be re-negotiated once the contract with the insurance company for reimbursement has ended. This generally occurs every 18-24 months. It is very important to remember the terms and period of your contract with insurance providers to be in a position to re-negotiate, and hopefully, receive fee increases. A good practice to get in the habit of is reviewing your fee schedules on an annual basis, as it is usually the dentist that initiates the re-negotiating process.

Negotiating fees has dramatically changed recently and is a lot of work. It is truly a difficult process. For instance, many costs have increased recently due to the COVID-19 pandemic. There are added costs for PPE, plexiglas shielding and air purifying systems. Let’s look into what is involved with negotiating fees with insurance companies.

Know Where You Stand

You must have accurate information to begin choosing what and how to negotiate with insurance companies. First, review your current office fee schedule. Examine them to find out how you compare with other dental practices in your local area. Maintain your bargaining power by making sure your fee schedule is not too low. Make sure your UCR fees are in the 80th percentile with other practices in your zip code.

You must be organized when negotiating fee schedule offers and remain politely persistent. Keep negotiating until all offers have been exhausted. Once you have agreed upon fees with an insurance provider, make sure to audit your insurance claims over the next three months to confirm the insurance provider is honoring the agreed-upon fee schedule. As a matter of fact, healthy protocol says to audit a dozen claims every six months to maintain the honor of the fee schedule.

Know Your Insurance Providers

Next is to determine the number of insurance companies with which you actually have a contract. You should have contracts with at least 10-plus insurance companies. Also, if you are contracted by one insurance company, it may turn out you are contracted with several companies. A lot of insurance companies contract with each other to share patients and fees. Always read the fine print when signing contracts with insurance providers, and remember to only sign with insurance companies you feel are necessary for your dental practice.

A good way to begin researching local insurance providers is to call the Human Resources Departments of businesses in your area to ask which company holds the contract for their dental benefits. Find out what plans are offered by the local major employers in your patient area. Don’t forget to consider schools, hospitals, federal and state offices and large nationally-owned companies. You may discover new opportunities to update your current plans with other plan agreements that will benefit your practice.

Know Your Leverage

When negotiating with insurance providers, be sure to make the provider aware of the ways it could benefit from entering a contract with your dental practice. To represent your leverage as a service provider, be knowledgeable about the following:

Added per patient cost due to COVID-19 related changes
Saturation of dentists in your area
Specialty services offered
Appointment availability for new patients and current subscribers
Your philosophy of care regarding preventive services
Availability of teledentistry
Your patient satisfaction rate
Electronic claim processing capacity
EFT-enabled for receipt of claims payments
Use of online portals for eligibility and pre-authorizations
Date of last contract increase compared to cost of living increase for same time

Know Your Dental Office Production

Based on your dental office production, determine which CDT codes are at the top of the list for your dental practice. Ninety percent of your practice’s billable production is usually covered by approximately 30 codes. Dental offices use these Current Dental Terminology codes to identify dental procedures which cover oral health. A procedural code has an alphanumeric code beginning with the letter “D” followed by four numbers. These codes are maintained by the American Dental Association (ADA).

Contact the Carriers

The final step is to contact the insurance carrier to speak to an agent, retention specialist or provider relations

manager/specialist to initiate the negotiations. Plan to discuss your decrease in revenue under your current contract along with all the advantages to the carrier your dental practice can provide. Ask for a review and increase in fee reimbursement for your top 30 codes. Inquire about receiving an additional per-visit fee to cover the addition of PPE expenses.

Ask the carrier if they have a co-lease agreement or network share agreement with any other carriers. Review the fees offered to you by the carrier and do not be afraid to make counter-proposals. Finally, when you accept fees, keep a detailed list of the contracts accepted, terms and all final fee schedules.

After consideration of all the steps involved in the negotiation of fees with insurance providers for your dental practice, you may decide negotiating with insurance companies appears to be too time consuming and too difficult. There are companies specifically designed to help you. These companies represent hundreds of dental offices and are familiar with negotiating with insurance companies. PPO Negotiation Solutions is there to help you! Contact them for your complimentary assessment and schedule a consultation today!